An Aging World: 2015

Transcript

1 An Aging World: 2015 International Population Reports By Wan He, Daniel Goodkind, and Paul Kowal Issued March 2016 P95/16-1 U.S. Department of Health and Human Services National Institutes of Health NATIONAL INSTITUTE ON AGING

2 Acknowledgments In Memory of Dr. Richard M. Suzman The Population Division of the U.S. Census Bureau wishes to express our deep gratitude and pay tribute to Dr. Richard M. Suzman , director of Division of Behavioral and Social Research, National Institute on Aging, who passed away on April 16, 2015. A pioneer and champion for the science of population aging, Dr. Suzman played a critical role in developing the aging research program in the Population Division. For over three decades he steadfastly supported numerous Census Bureau publications focused on population aging trends and demographic, socioeconomic, and health characteristics of the older populations in the United States and the world. Enormously popular report series such as 65+ in the United and are a remarkable testimony to Dr. Suzman’s dedication States An Aging World to research on population aging which, in his words, is reshaping our world. This report was prepared by Wan He and Daniel Goodkind of the U.S. Census Bureau, and Paul Kowal of the World Health Organization's (WHO) SAGE, under the direction Loraine A. West of , Chief, Demographic and Economic Studies Branch, and general direction of Glenn Ferri , Assistant Division Chief, International Programs and James , former Acting Assistant Division Chief, International Programs Center D. Fitzsimmons Karen Humes for Demographic and Economic Studies, Population Division. , Chief, Population Division provided overall direction. The authors wish to give special acknowledgment to the following researchers who graciously contributed to text boxes that focus on special and frontier research topics in population aging: , Robert Cumming , TU Dortmund University; Martina Brandt Karen I. Fredriksen- Christian Deindl , University of Cologne; University of Sydney; Goldsen , University of Washington; Mary C. McEniry , University of Wisconsin-Madison; Kirstin N. Sterner , University of Oregon. Joel Negin , University of Sydney; and Research for and production of this report were supported under an interagency agreement with the Division of Behavioral and Social Research, National Institute on Aging (NIA). The authors are grateful to many people within the Census Bureau who made this publi - cation possible by providing literature and data search, table and graph production, verifi- , cation, and other general report preparation: Samantha Sterns Cole , Laura M. Heaton , , Mary Beth Kennedy Iris Poe , Andrea Miles , Lisa R. Lollock , Robert M. Leddy, Jr. David Zaslow and . The authors give special thanks to Joshua Comenetz , Population Division, for his thorough review. Reviewers from NIA provided valuable comments and constructive suggestions, including: David Bloom , Harvard University; David Canning , Harvard University; Somnath Chatterji , World Health Organization; Eileen Crimmins , University of Southern California; Ronald D. Lee , University of California, Los Angeles, Berkeley; John Romley Alyssa Lubet , Harvard University; Angela M. O’Rand , Duke University; , , University of Michigan; and anony- Amanda Sonnega University of Southern California; mous reviewers from NIA. , Demographic Statistical James Farber Statistical testing review was conducted by Methods Division. For cartographic work, the authors thank Steven G. Wilson and John T. Fitzwater , Population Division. Christine E. Geter Linda Chen of the Census Bureau’s Public Information Office and and Faye Brock of the Center for New Media and Promotion provided publication management, graphics design and composition, and editorial review for print and elec - of the Census Bureau's Administrative and Customer George E. Williams tronic media. Services Division provided printing management.

3 Issued March 2016 An Aging World: 2015 P95/16-1 U.S. Department of Commerce Penny Pritzker, Secretary Bruce H. Andrews, Deputy Secretary Economics and Statistics Administration Justin Antonipillai, Counselor, Delegated Duties of Under Secretary for Economic Affairs U.S. CENSUS BUREAU John H. Thompson, Director

4 Suggested Citation Wan He, Daniel Goodkind, and Paul Kowal U.S. Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015 , U.S. Government Publishing Office, Washington, DC, 2016. ECONOMICS ATISTICS AND ST ADMINISTRATION Economics and Statistics Administration Justin Antonipillai, Counselor, Delegated Duties of Under Secretary for Economic Affairs U.S. CENSUS BUREAU John H. Thompson, Director Nancy A. Potok, Deputy Director and Chief Operating Officer Enrique Lamas, Associate Director for Demographic Programs Karen Humes, Chief, Population Division For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll-free 866-512-1800; DC area 202-512-1800 Fax: 202-512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

5 Contents Chapter 1. Introduction . . . . . . . . . . . . . . . . . . 1 3 . . . . . . . . . . . . . . . . . Chapter 2. Aging Trends Growth of world's older population will continue to outpace that of younger population over the next 35 years . . . . . . . . 3 Asia leads world regions in speed of aging and size of older population . . . . . . . . . . . . . . . . . . . . . . 6 Africa is exceptionally young in 2015 and will remain so in the foreseeable future . . . . . . . . . . . . . . . . . . . 6 World’s oldest countries mostly in Europe today, but some Asian and Latin American countries are quickly catching up . . . . . 9 The two population billionaires, China and India, are on drastically different paths of aging . . . . . . . . . . . . . . . . . 10 Some countries will experience a quadrupling of their oldest population from 2015 to 2050 . . . . . . . . . . . . . . 11 . . . . . . . . 15 Chapter 3. The Dynamics of Population Aging Total fertility rates have dropped to or under replacement level in all world regions but Africa . . . . . . . . . . . . . . 15 Fertility declines in Africa but majority of African countries still have above replacement level fertility in 2050 . . . . . . . . 18 Some countries to experience simultaneous population aging and population decline 22 . . . . . . . . . . . . . . . . . Composition of dependency ratio will continue to shift toward older dependency . . . . . . . . . . . . . . . . . . . 23 Median ages for countries range from 15 to near 50 . . . . . . 25 Sex ratios at older ages range from less than 50 to over 100 . . . 26 31 . . . . . . Chapter 4. Life Expectancy, Health, and Mortality Deaths from noncommunicable diseases rising . . . . . . . . 31 Life expectancy at birth exceeds 80 years in 24 countries while it is less than 60 years in 28 countries . . . . . . . . . . . 32 Living longer from age 65 and age 80 35 . . . . . . . . . . . . Yes, people are living longer, but how many years will be lived in good health? . . . . . . . . . . . . . . . . . . . . 36 Big impacts, opposite directions? Smoking and obesity 38 . . . . . Change is possible! . . . . . . . . . . . . . . . . . . . 44 What doesn’t kill you, makes you . . . possibly unwell 45 . . . . . . Presence of multiple concurrent conditions increases with age . . 48 Trend of age-related disability varies by country . . . . . . . . 48 Frailty is a predisabled state . . . . . . . . . . . . . . . . 49 The U-shape of subjective well-being by age is not observed everywhere . . . . . . . . . . . . . . . . . . . . . . 50 . . . . 65 Chapter 5. Health Care Systems and Population Aging Increasing focus on universal health care and aging . . . . . . . 65 Health systems in response to aging . . . . . . . . . . . . . 66 Health system’s response to aging in high-income countries . . . 69 Health system’s response to aging in low- and middle-income countries . . . . . . . . . . . . . . . . . . . . . . 70 Healthcare cost for aging populations . . . . . . . . . . . . 70 Cost is one thing... . . . . . . . . . . . . . . . . . . . 71 ...Ability to pay is another . . . . . . . . . . . . . . . . . 73 Long-term care needs and costs will increase . . . . . . . . . 74 Quantifying informal care and care at home . . . . . . . . . . 79 Other care options: Respite, rehabilitative, palliative, and end-of-life care 81 . . . . . . . . . . . . . . . . . . . . iii An Aging World: 2015 U.S. Census Bureau

6 Chapter 6. Work and Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Labor force participation rates vary sharply by age and sex . . . . . . . . . . . . . . . . . . 91 Older population in higher income countries less likely to be in labor force . . . . . . . . . . . . 92 Gender gap in labor force participation rate is narrowing 95 . . . . . . . . . . . . . . . . . . . Labor force participation among the older population continues to rise in many developed countries . . 95 Share of the older, employed population working part-time varies across countries . . . . . . . . . 98 Unemployment patterns vary across sexes and over time 102 . . . . . . . . . . . . . . . . . . . Expectations and realities—many workers uncertain about their lifestyle after retirement and many retire earlier than expected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Statutory retirement ages vary widely across world regions, yet tend to lump at certain ages . . . . . 108 . . . . . . . . . . . . . . . . . . . . . . . . . 115 Chapter 7. Pensions and Old Age Poverty Number of countries offering a public pension continues to rise . . . . . . . . . . . . . . . . . 115 Earnings-related pension programs are still the most common . . . . . . . . . . . . . . . . . 115 Public pension coverage greater in high-income countries . . . . . . . . . . . . . . . . . . . 117 Opinions differ on how to improve sustainability of public pension systems . . . . . . . . . . . . 119 The Chilean model undergoes further reform and some countries abandon it completely 122 . . . . . . . The bigger financial picture includes other sources of income . . . . . . . . . . . . . . . . . . 124 Families play a major support role in many societies . . . . . . . . . . . . . . . . . . . . . 126 Pensions can drastically lower poverty rates for the older population . . . . . . . . . . . . . . . 127 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Chapter 8. Summary Population growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Health and health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Work, retirement, and pensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 135 . . . . . . . . . . . . . . . . . . . . Appendix A. Country Composition of World Regions 137 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix B. Detailed Tables 165 . . . . . . . . . . . . . . . . . . . . . Appendix C. Sources and Limitations of the Data FIGURES 4 Figure 2-1. Percentage of Population Aged 65 and Over: 2015 and 2050 ... 5 ... . . . . . . Figure 2-2. World Population by Age Group: 2015 to 2050 Figure 2-3. Young Children and Older People as a Percentage of Global Population: 1950 to 2050 5 ... Figure 2-4. Population Aged 65 and Over by Region: 2015 to 2050 ... . . . . . . 8 ... Figure 2-5. Percentage Distribution of Population Aged 65 and Over by Region: 2015 and 2050 8 Figure 2-6. The World’s 25 Oldest Countries and Areas: 2015 and 2050 10 . . . . . . . . . . . . . . . Figure 2-7. Number of Years for Percentage Aged 65 and Older in Total Population to Triple: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Selected Countries Figure 3-1. Total Fertility Rate by Region: 2015, 2030, and 2050 15 . . . . . . . . . . . . . . . . . Figure 3-2. Population by Age and Sex for China: 2015 and 2050 . . . . . . . . . . . . . . . . . 17 Figure 3-3. Population by Age and Sex for Nigeria: 2015 and 2050 19 . . . . . . . . . . . . . . . . Figure 3-4. Population by Age and Sex for Kenya: 2015 and 2050 . . . . . . . . . . . . . . . . . 19 Figure 3-5. Percentage Distribution of Population Aged 50 and Over by Number of Surviving Children for Selected European Countries: 2006–2007 20 . . . . . . . . . . . . . . . . . . . . Figure 3-6. Type of Support Received by People Aged 50 and Over in Selected European Countries by . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Status: 2006–2007 21 Figure 3-7. Countries With Expected Decline of at Least 1 Million in Total Population From 2015 to 2050 . 22 Figure 3-8. Dependency Ratios for the World: 2015 to 2050 . . . . . . . . . . . . . . . . . . . 24 Figure 3-9. Dependency Ratios for Indonesia and Zambia: 1980, 2015, and 2050 . . . . . . . . . . . 24 Figure 3-10. Countries With Lowest or Highest Median Age in 2015: 2015, 2030, and 2050 25 . . . . . . . Figure 3-11. Difference Between Female and Male Populations by Age in the United States: 2010 . . . . . 26 Figure 3-12. Sex Ratio for World Total Population and Older Age Groups: 2015 . . . . . . . . . . . . 27 Figure 3-13. Sex Ratios for Population Aged 65 and Over for Bangladesh and Russia: 1990 to 2050 . . . . 28 Figure 4-1. Mean Age of Death in Global Burden of Disease Regions: 1970 and 2010 . . . . . . . . . 32 . . . . 35 Figure 4-2. Countries With Highest and Lowest Life Expectancy at Age 65 by Sex: 2015 and 2050 An Aging World: 2015 U.S. Census Bureau iv

7 Figure 4-3. Drivers of Incr ease or Decrease in Life Expectancy at Age 60 by Sex, Region, and Income: 1980 to 2011 36 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Life Expectancy (LE) and Healthy Life Years (HALE) at Age 65 by Sex for Figure 4-4. Selected European Countries: 2012 . . . . . . . . . . . . . . . . . . . . . . . 37 Percentage Distribution of Cumulative Risk Factors Among People Aged 50 and Over Figure 4-5. for Six Countries: 2007–2010 . . . . . . . . . . . . . . . . . . . . . . . . . 39 United States Healthy Life Expectancy at Age 65 by Sex and State: 2007–2009 . . . . . . . 40 Figure 4-6. Figure 4-7. . . . . . . . . . . . . . . . . . 43 Caloric Intake in Early Life and Diabetes in Later Life 2025 Deaths by Age, Income Level, and Projection Assumptions . . . . . . . . . 44 Figure 4-8. Projected Number of People Aged 50 and Over Living With HIV for Selected Regions: 1995 to 2013 . . . 47 Figure 4-9. Percentage With Comprehensive Knowledge About HIV and AIDS by Age and Country: Figure 4-10. Selected Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Figure 4-11. Activity of Daily Living Limitations by Age for the United States and England: 1998 to 2008 . . 49 Figure 4-12. and Happiness by Age and Sex in Four Regions: 2006–2010 . . . . . . . . . . 51 Well-Being issue and BMI . . . . . . . . . . . . . . . . . . . . . . 53 Figure 4-13. Age Acceleration in Liver T Proportion of Quality Measur es for Which Members of Selected Groups Experienced Better, Figure 5-1. Same, or Worse Quality of Care Compared With Reference Group in the United States: 2011 . . 69 Figure 5-2. Out-of-Pocket Health Car e Expenditures as a Percentage of Household Income by Age Group and Income Category in the United States: 2009 . . . . . . . . . . . . . . . . . . 71 Figure 5-3. Predicted Quarterly Primary Care Costs by Time to Death and Age in Italy: 2006–2009 . . . . 72 Figure 5-4. Source of Payment for Health Care Services by Type of Service for Medicare Enrollees Aged 65 and Over in the United States: 2008 73 . . . . . . . . . . . . . . . . . . . Figure 5-5. Financial Impacts of Having a Household Member Aged 50 and Over in Six Middle-Income Countries: 2007–2010 . . . . . . . . . . . . . . . . . . . 74 Figure 5-6. Percentage Receiving Long-Term Care Among Population Aged 65 and Over in Selected Countries: Circa 2011 . . . . . . . . . . . . . . . . . . . . . . . 75 Figure 5-7. owth Rate in Public Expenditure on Long-Term Care (LTC) in Institutions and at Annual Gr Home in Selected Countries: 2005–2011 . . . . . . . . . . . . . . . . . . . . . 76 Figure 5-8. Cumulative Gr owth in Elder Care Homes in Selected Chinese Cities: 1952 to 2009 . . . . . . 77 Percentage Figure 5-9. of Population Aged 50 and Over Who Report Being Informal Caregivers in Selected European Countries: 2010 . . . . . . . . . . . . . . . . . . . . . . 79 Figure 5-10. Percentage of Canadians Providing Care to Older Population or Receiving Care by Age Group: 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Figure 5-11. Percentage of Women Among Informal Caregivers Aged 50 and Over in Selected European Countries: 2010 . . . . . . . . . . . . . . . . . . . . . . 81 Figure 6-1. Labor Force Participation Rates for Population Aged 65 and Over by Sex and World Region: 2010 Estimate and 2020 Projection 93 . . . . . . . . . . . . . . . . . . . . . . . Figure 6-2. Labor Force Participation Rates for Population Aged 65 and Over for Selected African Countries: 2011 . . . . . . . . . . . . . . . . . . . . . . 94 Figure 6-3. Participation Rates for Men Aged 65 and Over in More Developed Countries: Labor Force 1990s and 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Participation Rates for Women Aged 65 and Over in More Developed Countries: Figure 6-4. Labor Force 1990s and 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Labor Force Participation Rates for Men Aged 65 and Over in Less Developed Countries: Figure 6-5. 1990s and 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Figure 6-6. Labor Force Participation Rates for Women Aged 65 and Over in Less Developed Countries: 1990s and 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Figure 6-7. Employed Men Aged 65 and Over by Country: 2013 . . . . . . . . 100 Employment Status of Figure 6-8. Employment Status of Employed Women Aged 65 and Over by Country: 2013 . . . . . . . 101 Figure 6-9. Unemployment Rate for Men and Women Aged 65 and Over by Country: 2005 and 2013 . . . 102 Figure 6-10. Unemployment Rate for Men and Women Aged 55 to 64 and Over by Country: 2005 and 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Unemployment Rates for Figure 6-11. Population Aged 25 to 54 and Aged 65 and Over for Portugal, South Korea, United Kingdom, and United States: 2000 to 2013 . . . . . . . . . . . 105 v An Aging World: 2015 U.S. Census Bureau

8 Figure 6-12. ork Plans After Retirement by Workers and Retirees for Selected Countries: 2013 . . . . . 106 W W Figure 6-13. orkers Who Are Not Confident About Having A Comfortable Lifestyle in Retirement by Country: 2013 107 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W orkers’ Expectations Regarding Standard of Living in Retirement in the United States Figure 6-14. by Generation: 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Figure 6-15. Per centage Distribution of Statutory Pensionable Age by Region and Sex: 2012/2014 . . . . 109 Number of Countries With Public Old Age/Disability/Survivors Programs: Figure 7-1. 1940 to 2012/2014 115 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contribution Rates for Old Age Social Security Programs by Country and Contributor: Figure 7-2. 2012 and 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Figure 7-3. oportion of Labor Force Covered by Public Pension Systems in Each Country: 2005–2012 . . 117 Pr Figure 7-4. Public Pension Net Replacement Rate for Median Earners by Country: 2013 . . . . . . . . 119 Figure 7-5. T otal Public Benefits to Population Aged 60 and Over as a Percentage of GDP: 2010 and 2040 Projection . . . . . . . . . . . . . . . . . . . . . . . . . . 120 ed Options to Increase Sustainability of Government Pensions by Country: 2013 . . . . 121 Figure 7-6. Favor Per centage of Labor Force Contributing to Individual Account Pensions by Country: Figure 7-7. 2004 and 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Figure 7-8. Income Distribution for Population Aged 65 and Over by Sour ce and Country: 2011 . . . . . 125 Figure 7-9. A verage Income Tax Rate for Ages 18–65 and Over Age 65 by Country: 2011 . . . . . . . 126 Figure 7-10. Poverty Rate for Total Population and Population Aged 65 and Over for OECD Countries: 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Figure 7-11. Poverty Rate for Total Population and Population Aged 65 and Over for Latin America and the Caribbean: 2005 to 2007 128 . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 7-12. Poverty Rate Among Those Aged 60 and Over by Percentage Receiving Pension in Latin America and the Caribbean: 2005 to 2007 . . . . . . . . . . . . . . . . . 129 TABLES Table 2-1. W 3 . . . orld Total Population and Population Aged 65 and Over by Sex: 2015, 2030, and 2050 Table 2-2. Aged 65 and Over by Region: 2015, 2030, and 2050 . . . . . . . . . . . . . 6 Population centage of Population Aged 80 and Over Projected to Quadruple: 2010–2050 . . 11 Table 2-3. Countries With Per T en Lowest and Highest Total Fertility Rates for African Countries: 2015, 2030, and 2050 Table 3-1. 18 . . . Table 3-2. Median Age by Sex and Region: 2015, 2030, and 2050 . . . . . . . . . . . . . . . . 25 Table 4-1. Age-Standardized Mortality Rates by Cause of Death, WHO Region, and Income Group: 2012 . 32 Table 4-2. at Birth by Sex for World Regions: 2015 and 2050 . . . . . . . . . . . . 33 Life Expectancy Table 4-3. Countries With Highest and Lowest Life Expectancy at Birth by Sex in 2015 and Projected for 2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 42 Table 4-4. GDP per Capita and Caloric Intake in Selected Countries and Areas: 1930s and 2000s . . . . Table 4-5. Disability-Adjusted Life Y ears (DALYs) Attributable to Chronic Noncommunicable Diseases for World Population Aged 60 and Over: 1990 and 2010 . . . . . . . . . . . 45 for Effect of Age, Sex, and Educational Attainment on Multimorbidity Table 4-6. Odds Ratios for World Regions: 2002–2004 . . . . . . . . . . . . . . . . . . . . . . . . . 48 Disability Table 4-7. . . . . . . . . . . . . . . . 48 Prevalence Rate by Age Group for Malawi: 2008 Table 5-1. Country Distribution of Share of Population Without Legal Health Coverage by Region . . . . 66 Table 6-1. Labor For ce Participation Rates by Age and Sex in Selected Countries: 2012 . . . . . . . . 92 Table 6-2. Gender Gap in Labor Force Participation Rates for Population Aged 65 and Over by Country: 1990s and 2012 . . . . . . . . . . . . . . . . . . . . . . . . . 95 Table 6-3. Labor For ce Participation Rates for Older Workers in Selected Countries: 2001 and 2011 . . . 99 Table 7-1. Number and Percentage of Public Pension Systems by Type of Scheme and World Region . . . 116 122 Characteristics of Latin American Individual Account Pensions: 2009 . . . . . . . . . . . Table 7-2. Aged 65 and Over in Poverty by Pension Status for Selected Countries Table 7-3. Population in Latin America and the Caribbean: 2005 to 2007 129 . . . . . . . . . . . . . . . . . An Aging World: 2015 eau U.S. Census Bur vi

9 BOXES Box 1-1. Geographic Terms in This Report . . . . . . . . . . . . . . . . . . . . . . . . . 2 Projections Data in This Report . . . . . . . . . . . . . . . . . . . . . 2 Box 1-2. Population Demographic Transition and Population Aging . . . . . . . . . . . . . . . . . . . . 7 Box 2-1. Box 2-2. of the Share of Older Population, or Is It Tripling? . . . . . . . . . . . . . . . 12 Doubling Box 3-1. China's One-Child Policy and Population Aging . . . . . . . . . . . . . . . . . . . . 16 Box 3-2. Support of Childless Older People in an Aging Europe . . . . . . . . . . . . . . . . . 20 Box 4-1. Life Conditions and Older Adult Health . . . . . . . . . . . . . . . . . . . . . 41 Early Box 4-2. The Rising Tide of Aging With HIV . . . . . . . . . . . . . . . . . . . . . . . . . 46 Box 4-3. Epigenetics of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Box 5-1. Global Aging and Minority Populations: Health Care Access, Quality of Care, and Use of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Networks and Health Care Utilization Box 5-2. Social . . . . . . . . . . . . . . . . . . . . . 78 Box 6-1. of the Great Recession on the Older Population . . . . . . . . . . . . . . . . 104 Impact Demographic Dividend?—Age Structure, Savings, and Economic Growth . . . . . . 110 Box 6-2. A Second Defined Benefit and Defined Contribution Pensions in Selected African Countries . . . . . . 118 Box 7-1. Box 7-2. s Second Round of Pension Reform . . . . . . . . . . . . . . . . . . . . . . 124 Chile’ APPENDIX TABLES Total Population, Percentage Older, and Percentage Oldest Old: 1950, 1980, 2015, and 2050 . . 137 Table B-1. Table B-2. Percentage Change in Population for Older Age Groups by Country: 2010 to 2030 and 2030 to 2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Table B-3. . . . . . . . . . . . . . . . . . . . . . . . . 144 Median Age: 2015, 2030, and 2050 Table B-4. Sex Ratio for Population 35 Years and Over by Age: 2015, 2030, and 2050 . . . . . . . . 148 Table B-5. Dependency Ratios: 2015, 2030, and 2050 . . . . . . . . . . . . . . . . . . . . . 152 Table B-6. Life Expectancy at Birth, Age 65, and Age 80 by Sex for Selected Countries: 2015 and 2050 . . 156 Table B-7. Deficits in Universal Health Protection: Share of Total Population Without Health Protection by Country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Table B-8. 160 . . . Labor Force Participation Rates by Age, Sex, and Country: Selected Years, 1980 to 2012 vii An Aging World: 2015 U.S. Census Bureau

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11 CHAPTER 1. Introduction countries are projected to continue The world population continues to This report covers the demographic, to grow in size, but at a much grow older rapidly as fertility rates health, and economic aspects of have fallen to very low levels in slower pace than those in less global population aging. After an developed countries, particularly in most world regions and people tend examination of past and projected to live longer. When the global pop- Asia and Latin America. By 2050, growth of the older population less than one-fifth of the world’s ulation reached 7 billion in 2012, and dynamics of population aging older population will reside in more 562 million (or 8.0 percent) were (chapters 2 and 3), the report then developed countries. aged 65 and over. In 2015, 3 years covers health, mortality, and health later, the older population rose by care of the older population (chap- There are great variations within 55 million and the proportion of the ters 4 and 5). Finally, work, pen- the less developed world as well. older population reached 8.5 per - sions, and other economic charac- Asia stands out as the population 1 With cent of the total population. teristics of older people (chapters 6 giant, given both the size of its the post World War II baby boom and 7) are addressed. Compared to older population (617.1 million in generation in the United States and previous versions of the report An 2015) and its current share of the Europe joining the older ranks in Aging World , this edition is unique world older population (more than recent years and with the acceler - for expanding the analysis of aging half). By 2050, almost two-thirds ated growth of older populations trends to all countries and areas, of the world’s older people will live in Asia and Latin America, the next - with an emphasis on the differ in Asia. Even countries experienc- 2 Where 10 years will witness an increase ences among world regions. ing slower aging will see a large data are available, it also updates of about 236 million people aged increase in their older populations. ends for the latest statistics and tr 65 and older throughout the world. Africa, for instance, is projected health and economic indicators. Thereafter, from 2025 to 2050, the to still have a young population This edition also includes an assess- older population is projected to in 2050 (with those at older ages ment of the impact of the recent almost double to 1.6 billion glob- projected to be less than 7 percent global recession on older people’s ally, whereas the total population of the total regional population), yet economic well-being. Moreover, it will grow by just 34 percent over the projected 150.5 million older includes some frontier research on the same period. Africans would be almost quadruple special topics of population aging in Yet the pace of aging has not been the 40.6 million in 2015. the form of text boxes contributed uniform. A distinct feature of global by non-Census Bureau researchers - Population aging, while due primar population aging is its uneven with expertise in those fields. ily to lower fertility, also reflects a speed across world regions and human success story of increased More specifically, Chapter 2, “Aging development levels. Most of the longevity. Today, living to age 70 Trends,” opens the report and more developed countries in Europe or age 80 is no longer a rarity in examines the continuing global have been aging for decades, some many parts of the world. However, aging trend and projected growth of for over a century. In 2015, 1 in 6 increasing longevity has led to the population aged 65 and over. It people in the world live in a more new challenges: How many years also discusses the variations in pop- developed country, but more than a can older people expect to live in ulation aging among world regions third of the world population aged good health? What are the chronic and countries. Chapter 3, “The 65 and older and over half of the diseases that they may have to Dynamics of Population Aging,” world population aged 85 and older deal with? How long can they live analyzes fertility decline, the main live in these countries. The older independently? How many of them propeller of population aging, for populations in more developed are still working? Will they have - regions and countries. It also exam sufficient economic resources to ines aging indicators, including 1 Definitions of the older population, last their lifetimes? Can they afford youth, and working age vary across the world 2 health care costs? The world is fac- because of differences in age distribution. For Population projections data encompass the purpose of this report, unless specified all countries and areas of the world, while ing these and many more questions otherwise, “older population” refers to those health and economic data are more limited in as population aging continues. aged 65 and over, “youth” refers to those coverage across countries and regions. In this under age 20, and “working-age population” report, the term “countries” includes countries refers to ages 20 to 64. and areas. 1 An Aging World: 2015 U.S. Census Bureau

12 dependency ratios, median age, and sex ratios. Chapters 4 and 5 cover Box 1-1. Geographic Terms in This Report health and health care related areas, with Chapter 4, “Life Expectancy, World regions in this report follow United Nations categories—Africa, Health, and Mortality,” reporting on Asia, Europe, Latin America and the Caribbean, Northern America, and extended life expectancy at birth Oceania—unless otherwise noted. See Appendix A for a list of coun- and at older ages, with empha- tries and areas in each region. sis on healthy life expectancy. The “more developed” and “less developed” country categories used Chapter 4 also discusses leading in this report correspond to the classification employed by the United causes of death and health condi- Nations. The “more developed” countries include all of Northern tions and well-being for the older America and Europe plus Japan, Australia, and New Zealand. The “less population. Chapter 5, “Health developed” countries include all of Africa, all of Asia except Japan, the Care Systems and Population Transcaucasian and Central Asian republics, all of Latin America and Aging,” covers health systems’ the Caribbean, and all of Oceania except Australia and New Zealand. response to population aging, including universal health care. It also examines cost and affordabil- Chapter 7 also presents poverty series—prior reports Aging World ity of health care, long-term care, levels for the older population and were published in 1987, 1993, and informal care for the older the crucial role of pensions. The 2001, and 2008. The Census Bureau population. The last two chapters data used in this report draw heav- has produced other cross-national examine the economic well-being ily from the U.S. Census Bureau’s reports covering aging trends and of the older population. Chapter International Data Base, as well as the characteristics of the older pop- 6, “Work and Retirement,” updates databases developed and main- ulation, including Aging in the Third international trends in labor force tained by organizations such as the (1988), World Aging in Eastern participation, with special atten- United Nations, the World Health Europe and the Former Soviet Union tion to broad economic dynamics, Organization, the Organisation (1993), and Population Aging in such as the second demographic for Economic Co-operation and Sub-Saharan Africa: Demographic dividend of changing aging struc- Development, and the International Dimensions 2006 . This report and ture. Chapter 7, “Pensions and Old Labour Organization. The report all previously released international Age Poverty,” reviews recent trends also incorporates data and findings aging reports were commissioned in international pension systems, from the literature. by the National Institute on Aging, such as their coverage of the older Division of Behavioral and Social is the fifth An Aging World: 2015 population and their sustainability. Research. An report in the Census Bureau’s Box 1-2. Population Projections Data in This Report Throughout this report, projections of population size and composition come from the Population Division of the Census Bureau, unless otherwise indicated. As discussed further in Appendix C, these projections are based on demographic analysis for each nation, including their population age and sex structures, compo- nents of population change (rates of fertility, mortality, and net migration), and assumptions about the future trajectories of population change. Projections for countries are updated periodically as new data become available. Therefore, the data in this report are not the latest available for every country and, by extension, for groups of countries aggregated into regions. The impact of projection updates on indicators of population aging is generally modest and has little effect on the overall trends described in this report. Population projections for the United States in this report come from the Census Bureau National Projections Data , current as of December 2014. Users may find the latest population figures for the United States at . The population projections for all other countries were current as of December 2013 and were drawn from the Census Bureau’s International Data Base. The latest projections for countries of the world are available at . An Aging World: 2015 U.S. Census Bureau 2

13 CHAPTER 2. Aging Trends The world population is aging population (aged 20 to 64) will GROWTH OF WORLD’S rapidly. Today the older population increase only moderately, 25.6 OLDER POPULATION WILL (aged 65 and over) represents 7 percent. The working-age popula- CONTINUE TO OUTPACE THAT OF YOUNGER percent or more of the total popula- tion share of total population will POPULATION OVER THE tion in many parts of the world— shrink slightly in the decades to NEXT 35 YEARS one notable exception is Africa and come, largely due to the impact parts of Asia, and Latin America of low fertility and increasing life Among the 7.3 billion people and the Caribbean (Figure 2-1). By expectancy. worldwide in 2015, an estimated 2050, only 33 countries are pro- 8.5 percent, or 617.1 million, are Perhaps an even more telling jected to have an older population aged 65 and older (Table 2-1). The illustration of the sharply different comprising less than 7 percent of number of older people is projected growth trajectories of the older their total population, a substantial to increase more than 60 percent and younger populations is the reduction from 115 such countries in just 15 years—in 2030, there converging, crossing, and then in 2015. At the same time, the will be about 1 billion older people diverging of the percentages of share of the older population will globally, equivalent to 12.0 percent older people and children under exceed 21 percent in 94 countries, of the total population. The share age 5 from 1950 to 2050 (Figure - including 39 countries with 28 per of older population will continue to 1 For the first time in human 2-3). cent or more of their total popula- grow in the following 20 years—by history, people aged 65 and over tion being older. 2050, there will be 1.6 billion older will outnumber children under age people worldwide, representing 5. This crossing is just around the The demographic phenomenon of 16.7 percent of the total world corner, before 2020. These two age population aging is known to many, population of 9.4 billion. This is groups will then continue to grow although the variation and diversity equivalent to an average annual in opposite directions. By 2050, the might surprise some. How fast will increase of 27.1 million older proportion of the population aged the older populations in the world people from 2015 to 2050. 65 and older (15.6 percent) will be grow in the next few decades? more than double that of children - What are the similarities and differ In contrast to the 150 percent under age 5 (7.2 percent). This ences among world regions? Which expansion of the population aged unique demographic phenomenon regions or countries are projected 65 and over in the next 35 years, of the “crossing” is unprecedented. to age the fastest? Conversely, the youth population (under age which regions or countries will not 20) is projected to remain almost experience population-aging pres- flat, 2.5 billion in 2015 and 2.6 sure in the near future? billion in 2050 (Figure 2-2). Over 1 Data for population shares aged 65 and the same period, the working-age over and under age 5 for 1950 to 2050 come from the United Nations, 2013. Table 2-1. World Total Population and Population Aged 65 and Over by Sex: 2015, 2030, and 2050 (Numbers in millions) Population aged 65 and over Percentage aged 65 and over Total population Year Both sexes Male Female Both sexes Male Female Both sexes Male Female 7,253.3 2015. . . . . . . . . . . . . 3,652.0 3,601.3 617.1 274.9 342.2 8.5 7.5 9.5 2030. . . . . . . . . . . . . 8,315.8 4,176.7 4,139.1 998.7 445.2 553.4 12.0 10.7 13.4 16.7 14.9 18.5 698.5 . . . . . . . . . . . . . 9,376.4 4,681.7 4,694.7 1,565.8 867.3 2050 Source: U.S. Census Bureau, 2013; International Data Base. 3 An Aging World: 2015 U.S. Census Bureau

14 Figure 2-1. Percentage of Population Aged 65 and Over: 2015 and 2050 2015 2050 Percent 28.0 or more 21.0 to 27.9 14.0 to 20.9 7.0 to 13.9 Less than 7.0 World percent 2015: 8.5 2050: 16.7 Sources: U.S. Census Bureau, 2013, 2014; International Data Base, U.S. population projections. An Aging World: 2015 U.S. Census Bureau 4

15 Figure 2-2. World Population by Age Group: 2015 to 2050 5,256 (In millions) 20–64 4,186 2,554 0–19 2,450 1,566 65 and over 617 447 80 and over 126 2035 2040 2045 2015 2030 2050 2025 2020 Source: U.S. Census Bureau, 2013; International Data Base. Figure 2-3. Young Children and Older People as a Percentage of Global Population: 1950 to 2050 Percent 18 16 14 Under 5 12 10 8 6 65 and over 4 2 0 1950 2050 2040 2030 2020 2010 2000 1990 1980 1970 1960 Source: United Nations, 2013. An Aging World: 2015 5 U.S. Census Bureau

16 America are similar, there are seven percent in 2030 and 18.8 percent ASIA LEADS WORLD times as many older people in Asia in 2050. REGIONS IN SPEED OF as in Latin America in 2015, and AGING AND SIZE OF OLDER By comparison, Europe is further POPULATION thus this ratio will be maintained in along in the demographic transi - 2050. World regions vary in their par - tion and will remain the oldest ticular phase of the demographic Some South-Eastern and South- region through 2050, even though transition and differ in their speed Central Asian countries are still the pace of aging will slow dras - of aging. Using the share of the tically. In 2015, 17.4 percent of young in 2015 (percentage of older population as an indicator for older population less than 7), Europeans are aged 65 or older. In aging, Europe historically has been but the size of their older popu most European countries, the share - the oldest region. However, Asia lation has already surpassed 5 of the older population already and Latin America are rapidly pro - million—Indonesia, 16.9 million; exceeds 14 percent. By 2050, more gressing through the demographic than a quarter of Europeans will Bangladesh, 8.7 million; Pakistan, 2 transition and population aging. - 8.7 million; and Vietnam, 5.5 mil be aged 65 and over, and in all lion. By 2050, the population aged but two European countries (Faroe Less than 8 percent of Asians are Islands and Kosovo) the older 65 and over in these countries will aged 65 and older in 2015 (Table population will represent at least more than triple to 57.2 million, 2-2), but this regional average 36.6 million, 32.8 million, and 23.0 20 percent of the total population. masks sharp variations within million, respectively. Asia. While about half of the Asian What warrants attention is that countries currently have less than while population aging in Asia AFRICA IS EXCEPTIONALLY a 5 percent share for the older currently is not as advanced as in YOUNG IN 2015 AND population, some countries in Europe or Northern America, its WILL REMAIN SO IN THE Asia are among the oldest in the huge population size simply can - FORESEEABLE FUTURE world. The young countries mostly not be ignored (Figure 2-4). Home Unlike all other regions, Africa, are located in South-Central Asia to China and India—countries the youngest region, is still largely (e.g., Afghanistan, 2.5 percent), with total populations exceeding in the early stages of the demo - South-Eastern Asia (e.g., Laos, 3.8 1 billion each currently—Asia’s graphic transition with high fertility percent), and Western Asia (e.g., modest 7.9 percent share of older rates and a young age structure, Kuwait, 2.3; Yemen, 2.7 percent; population translates into 341.4 especially in Western, Middle, and and Saudi Arabia, 3.2 percent). In million people aged 65 and over. some Eastern African countries. contrast, East Asia is one of the They represent 55.3 percent of The vast majority of African coun - - oldest sub-regions globally, includ the world’s total older population tries today have less than 5 per - ing the oldest major country in (Figure 2-5). By 2050, 975.3 mil - cent of the total population aged the world—Japan (26.6 percent). lion older people are projected to 65 and over, and in 21 countries The share of the older population be living in Asia, accounting for the share is 3 percent or less (e.g., in Asia is expected to reach 12.1 nearly two-thirds (62.3 percent) of Ethiopia, 2.9 percent and Uganda, the world’s total older population. 2.0 percent). 2 In this report, “Latin America” and In addition, while the projected “Latin America and the Caribbean” are used speed of aging for Asia and Latin interchangeably. Table 2-2. Population Aged 65 and Over by Region: 2015, 2030, and 2050 Population (in millions) Percentage of regional total population Region 2015 2050 2030 2050 2015 2030 70.3 150.5 3.5 4.4 6.7 Africa ... 40.6 341.4 ... 587.3 975.3 7.9 Asia 18.8 12.1 17.4 196.8 169.1 129.6 ... Europe 27.8 22.8 Latin America and the Caribbean 47.0 82.5 139.2 7.6 11.8 18.6 ... Northern America ... 53.9 82.4 94.6 15.1 20.7 21.4 16.2 Oceania 4.6 7.0 9.5 12.5 ... 19.5 Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 U.S. Census Bureau 6

17 Box 2-1. Demographic Transition and Population Aging The classical model of demographic transition refers to the process where a society starts with extremely high levels of both fertility and mortality and transitions to a point where both rates are low and stable. The demographic transition impacts both the population growth rate and the age structure of a country. The demographic transition consists of four stages. At the start—Stage 1, both birth rates and death rates are high. The natural increase (births minus deaths) is low, the population increases very slowly, and the country’s age structure is young with a pyramid shape of a large number of children at the base and very few older people at the top. In Stage 2, mortality, especially infant and child mortality, declines rapidly while fertility lags and remains high. In this stage, population increases rapidly and the age structure becomes younger. However, the proportion of the older population starts to grow as mortality rates decrease and people live longer. In Stage 3, a fertility transition occurs as fertility declines rapidly, accompanied by con - tinued yet slower declines in infant and child mortality, but accelerated mortality decline at older ages. The population continues to grow; however, the age structure becomes even older as life expectancy continues to improve. In Stage 4, both mortality and fertility are low and remain relatively stable, population growth flat- tens, and the age structure becomes old. No longer is there a wide base of young children and a small tip at the top for the older population; the shape of the age structure becomes almost rectangular. Many factors contribute to this process, but it is generally agreed that the initial momentum starts with improvement in public health, including basic sanitation and advancements in medicine. The increased child survival rates, along with general improvements in socioeconomic conditions, then affect fertility behavior through a reduction in the desired number of children. Economic explanations for a lower desired number of children include mechanization of agriculture and expansion of the nonagrarian economy; the quantity- quality tradeoff, that parents switch their resources from raising many offspring to a smaller number of “qual- ity” children; and the opportunity cost for women to have children versus their own labor force participation (Canning, 2011; Galor, 2012). Countries vary in the timing of the onset and duration of the stages of the demographic transition. The more developed countries, especially those in Western and Northern Europe, started the demographic transition more than a century ago and most took many decades to complete this process. Less developed countries in Asia and Latin America started this process only in recent decades, and for most of these countries, the tran- sition is proceeding more quickly. A number of countries in Sub-Saharan Africa are proceeding slowly through the fertility transition or in some cases experiencing a stall in fertility decline (Bongaarts, 2008). Researchers point to several possible explanations for the delays in fertility decline in parts of Africa, including slow economic development, limited improvement in female access to education, and increases in mortality due to the AIDS epidemic (Bongaarts, 2008; Ezeh, Mberu, and Emina, 2009). On the other hand, Bangladesh serves as an example of a country achieving major reductions in fertility from the mid-1970s to the mid-1990s despite low levels of economic development (Cleland, et al., 1994; Khuda and Hossain, 1996). 7 An Aging World: 2015 U.S. Census Bureau

18 Figure 2-4. Population Aged 65 and Over by Region: 2015 to 2050 Millions 1,600 Africa 1,400 1,200 1,000 Asia 800 600 400 Europe Latin America 200 and the Caribbean Northern America/ 0 Oceania 2015 2020 2030 2025 2050 2045 2040 2035 Source: U.S. Census Bureau, 2013; International Data Base. Figure 2-5. Percentage Distribution of Population Aged 65 and Over by Region: 2015 and 2050 2050 2015 Northern Northern America/ America/ Africa Africa Oceania Oceania 6.6% 9.6% 6.6% 9.5% Latin Latin America America and and the Caribbean the Caribbean 8.9% 7.6% Europe 12.6% Asia Europe Asia 62.3% 21.0% 55.3% Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 eau U.S. Census Bur 8

19 still among the oldest countries in 10 million (Nigeria, 18.8 million; Africa, as a region, is exceptional Egypt, 18.1 million; and Ethiopia, 2050, will move down the list; and not only for being young in 2015, 11.5 million) and another 6 coun - but also for being projected to Sweden, previously near the top, remain young over the next few tries with more than 5 million. will be passed by many fast-aging countries and areas and drop to decades, largely because of sus - WORLD’S OLDEST 84th in 2050. tained high fertility levels leading COUNTRIES MOSTLY IN to a young age structure in most The United States, with an older EUROPE TODAY, BUT Sub-Saharan countries. By 2050, the proportion of 14.9 percent in 2015 SOME ASIAN AND LATIN older population share is projected and ranked 48th among the oldest AMERICAN COUNTRIES ARE to continue below 7 percent in countries of the world, is rather QUICKLY CATCHING UP Africa. For example, Malawi’s older young among more developed population represents 2.7 percent The percentage of the population countries. Immigration may play a of the total population in 2015, and aged 65 and over in 2015 ranged role, as foreign-born mothers have its share is projected to increase to from a high of 26.6 percent for higher fertility levels than native only 4.2 percent by 2050. Similarly, - Japan to a low of around 1 per women and the foreign-born share Mozambique’s share of the older cent for Qatar and United Arab of births is disproportionately population is projected to reach Emirates. Of the world’s 25 oldest higher than their share in the total 3.3 percent in 2050, up from 2.9 countries and areas in 2015, 22 population (Livingston and Cohn, percent in 2015. are in Europe, with Germany or 4 2012). Even with the large infusion Italy leading the ranks of European of older people from the post-WWII It should be noted that most of countries for many years (Kinsella Baby Boom cohort (people born Northern Africa departs from the and He, 2009), including currently between mid-1946 and 1964) that African regional pattern—in Tunisia, 3 In 2050, Slovenia and (Figure 2-6). - the older population share is pro began in 2011, the older share of Bulgaria are projected to be the old - total population in 2050 (projected jected to rise from 8.0 percent in est European countries. 2015 to 24.3 percent in 2050; and to be 22.1 percent) will push the Morocco, from 6.4 percent in 2015 - United States down to 85th posi Japan, however, is currently the to 18.6 percent in 2050. A number tion, in the middle range among all oldest nation in the world and is of Eastern African countries will countries in the world. Because of projected to retain this position their rapid aging, Asian countries also age relatively rapidly in the through at least 2050. With the next 35 years; for example, the such as South Korea (35.9 percent), rapid aging taking place in Asia, older population share in Kenya is Taiwan (34.9 percent), and Thailand South Korea, Hong Kong, and projected to triple from 2015 (2.9 (27.4 percent), and Latin American Taiwan will join Japan at the top countries such as Cuba (28.3 percent) to 2050 (9.2 percent). of the list of oldest countries and percent) and Chile (23.2 percent) areas by 2050, when more than While Africa is a young region, are projected to be older than the one-third of these Asian countries’ some African countries already United States in 2050, even though total populations are projected have a large number of older they are younger than the United to be aged 65 and over. The oft- people. In 2015, the older popula - States in 2015. Tunisia stands out mentioned European countries, tion exceeds 1 million in 11 African as an African country that will rank such as Germany and Italy, while countries, including Nigeria, 5.6 69th in the world in 2050 with 24.3 million; Egypt, 4.6 million; and 3 The list of 25 oldest countries and percent aged 65 and over (older areas includes countries and areas with a South Africa, 3.1 million. By 2050, than the United States), up from a total population of at least 1 million in 2015. - more than half of all African coun Some small areas/jurisdictions have high 97th ranking in 2015. proportions of older residents. For example, tries are projected to have more in 2015, 30.4 percent of all residents of the - than 1 million older people, includ European principality of Monaco were aged 4 ing 3 countries that will exceed 65 and over, and the share is projected to See Chapter 3 for more discussion on fertility and population aging. reach 59 percent by 2050. An Aging World: 2015 9 U.S. Census Bureau

20 Figure 2-6. The World's 25 Oldest Countries and Areas: 2015 and 2050 Asia Europe Northern America Japan Japan Germany South Korea Italy Hong Kong Greece Taiwan Finland Slovenia Sweden Bulgaria Bulgaria Estonia Austria Greece Belgium Bosnia and Herzegovina Estonia Lithuania Portugal Poland Denmark Romania France Latvia Slovenia Spain Croatia Italy Hungary Portugal Czech Republic Puerto Rico Netherlands Austria Switzerland Germany Canada Slovakia Spain Hungary United Kingdom Croatia Serbia Ukraine Latvia Czech Republic Puerto Rico Serbia 20 10 40 30 0 40 30 20 10 0 Percentage of population aged 65 and over Percentage of population aged 65 and over 2050 2015 Note: The list includes countries and areas with a total population of at least 1 million in 2015. Source: U.S. Census Bureau, 2013; International Data Base. - level in India has remained well China and become the most popu THE TWO POPULATION above the level in China since the lous country in the world. BILLIONAIRES, CHINA 1970s. Historic fertility levels have AND INDIA, ARE ON However, these two population DRASTICALLY DIFFERENT affected the pace of aging in these giants are on drastically different PATHS OF AGING two countries. In 2015, the older paths of population aging, thanks population in China represents In 2015, the total population of largely to different historical fertil - 10.1 percent of its total population, China stands at 1.4 billion, with ity trends. Although both China and while the share is only 6.0 percent India close behind at 1.3 billion. India introduced family planning in India. By 2030, after India is It is projected that 10 years from programs decades ago (see Box projected to have overtaken now, by 2025, India will surpass 3-2 for a discussion of the impact China in terms of total population, of China’s program), the fertility 8.8 percent of India’s population An Aging World: 2015 U.S. Census Bureau 10

21 will be aged 65 and older, or 128.9 speed of aging, only one European SOME COUNTRIES million people. In contrast, in the country, Bosnia and Herzegovina, WILL EXPERIENCE A same year, China will have nearly is projected to see a quadrupling of QUADRUPLING OF THEIR OLDEST POPULATION FROM twice the number and share of their population aged 80 and over 2015 TO 2050 during the 2015 to 2050 period. older population (238.8 million and 17.2 percent). By 2050, it is The older population itself has Within the oldest populations, projected that China will have 100 - been aging, with the oldest seg those at extremely old ages (90 million more older people than ment growing faster than the and older, or 100 and older) are India, 348.8 million compared with younger segment because of growing faster than their younger 243.4 million, even though China’s increasing life expectancy at older counterparts in some countries, projected total population of 1.304 ages. In the United States, for even though they are a very small billion will be 352.8 million fewer example, life expectancy at age 65 portion of the total population. than India’s total population of increased from 11.9 years in 1900– From 1980 to 2010, U.S. census 1.657 billion. 1902 to 19.1 years in 2010, and for data showed that the 90 and older - age 80 from 5.3 to 9.1 years dur population almost tripled over - The sheer size of China’s older pop ing the same span of time (Arias, ulation can be further illustrated by the period, compared to a dou - 2014). Worldwide, the population bling of the population aged 65 - comparing its 65-and-older popula aged 80 and over is projected to tion with the population of all ages to 89 (He and Muenchrath, 2011). more than triple between 2015 and in some other populous countries. Centenarians, people aged 100 or 2050, from 126.5 million to 446.6 older, increased by 65.8 percent in In 2015, the number of older peo - million (Figure 2-2). the United States during the same ple in China (136.9 million) exceeds - period of time (Meyer, 2012). These Japan’s total population (126.9 mil The 80-and-older population in oldest old people are distinct from lion). In 2030, the total projected some rapidly aging Asian and Latin populations of Japan plus Egypt the rest of the older population in American countries will go through many sociodemographic character - (231.8 million) will be smaller remarkable growth; their share of istics and are more likely to have than China’s projected 65-and- the total population in the next chronic conditions that require older population (238.8 million). 35 years is projected to quadruple long-term care, thus may consume By 2050, it will take the combined from 2015 to 2050 (Table 2-3). In total populations of Japan, Egypt, public resources disproportionately Asia, 23 countries are projected - Germany, and Australia (345.6 mil and constitute a heavier burden to experience this quadrupling. In lion) to match the older population on informal care often provided by contrast, because the vast majority in China (348.8 million). families (National Institute on Aging of European countries started the and U.S. Department of State, aging process long ago and now 2007; Tsai, 2010). are experiencing a slowdown in the Table 2-3. Countries With Percentage of Population Aged 80 and Over Projected to Quadruple: 2010–2050 Africa ... Cote d’Ivoire, Egypt, Libya, Mauritius, Tunisia Asia ... Bahrain, Bangladesh, Brunei, Burma, Cambodia, China, India, Indonesia, Kuwait, Malaysia, Mongolia, North Korea, Qatar, Saudi Arabia, Singapore, South Korea, Syria, Thailand, Timor-Leste, Turkey, Turkmenistan, United Arab Emirates, Vietnam Europe ... Bosnia and Herzegovina Brazil, Colombia, Costa Rica, Cuba, Nicaragua, Trinidad and Tobago Latin America and the Caribbean ... Northern America; Oceania ... Papua New Guinea Note: The list includes countries with a total population of at least 1 million in 2015. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 11 U.S. Census Bureau

22 Box 2-2. Doubling of the Share of Older Population, or Is it Tripling? A commonly used indicator for the speed of population aging is the number of years for a country’s popula - tion aged 65 and over to double from 7 percent of the total population to 14 percent. It is often noted that it took France 115 years for its share of older population to achieve this doubling, and many European and Northern American countries waited more than half a century for this doubling to complete—Sweden, 85 years; Australia, 73 years; and the United States, 69 years (Figure 2-7). Japan is an exception among the more devel - oped countries. It took Japan only 25 years (1970 to 1995) to have its older population double from 7 percent to 14 percent of its total population. While most of the more developed countries have already completed this doubling, the less developed coun - tries, especially those in Asia and Latin America, started this process in the 21st century and are moving at a much faster speed. That the doubling may take only a couple of decades in China and many other Asian and Latin American countries raises serious concerns in these countries regarding their readiness to deal with a rap - idly aging society. As the Director-General of the World Health Organization pointed out at the United Nation’s Second World Assembly on Ageing in 2002, “We must be aware that the developed countries became rich before they became old, the developing countries will become old before they become rich” (Butler, 2002). In the near future, countries may face not just doubling but tripling of the share of the older population from 7 percent to 21 percent of the total population. Japan, the oldest country in the world, achieved its tripling in 2007, and today’s older Japanese represent about 27 percent of the total population. Projections show that by 2030, a short 15 years from now, the majority of European countries (32 out of 42) will have completed this tripling. The tripling will take place in some rapidly aging Asian and Latin American countries at an accelerated pace. South Korea, for example, is projected to take just 18 years for its older population to double from 7 percent to 14 percent, and half that time (9 years) to reach 21 percent. Chile’s doubling will take 26 years and just another 16 years to complete the tripling. Figure 2-7. Number of Years for Percentage Aged 65 and Older in Total Population to Triple: Selected Countries (Number of years) France (1865–2022) 157 42 115 Sweden (1890–2015) 85 40 125 United Kingdom (1930–2030) 55 45 100 99 26 Australia (1938–2037) 73 89 United States (1944–2033) 20 69 Spain (1947–2028) 36 45 81 80 27 Hungary (1941–2021) 53 Poland (1966–2024) 13 58 45 16 42 Chile (1999–2041) 26 17 Brazil (2012–2050) 38 21 37 13 Tunisia (2007–2044) 24 37 25 12 Japan (1970–2007) Years to increase from Years to increase from 6 14 21 Thailand (2003–2038) 35 7 percent to 14 percent 14 percent to 21 percent 34 11 China (2001–2035) 6 23 27 South Korea (2000–2027) 9 18 5 Sources: Kinsella and Gist, 1995; U.S. Census Bureau, 2013, 2014; International Data Base, U.S. population projections. An Aging World: 2015 U.S. Census Bureau 12

23 Chapter 2 References Galor, Oded. 2012. “The National Institute on Aging (NIA) Demographic Transition: Causes and U.S. Department of State. Arias, Elizabeth. 2014. United and Consequences.” The 2007. Why Population Aging States Life Tables, 2010 . Institute for the Study of Labor Matters: A Global Perspective . National Vital Statistics Reports (IZA) Discussion Paper 6334. National Institute on Aging 63/7. Hyattsville, MD: National of National Institutes on Center for Health Statistics. He, Wan and Mark N. Muenchrath. Health Publication 07-6134. 2011. 90+ in the United Washington, DC: National Bongaarts, John. 2008. “Fertility . American States: 2006–2008 Institute on Aging of National Transitions in Developing Community Survey Reports, Institutes on Health. Countries: Progress or ACS-17, U.S. Census Bureau. Stagnation?” Population Council Washington, DC: U.S. Tsai, Tyjen. 2010. More Caregivers Poverty, Gender, and Youth Government Printing Office. Needed Worldwide for the Working Paper 7. “Oldest Old.” Washington, DC: Khuda, Barkat-e- and Mian Bazle Population Reference Bureau. Butler, Robert N. 2002. “Guest Hossain. 1996. “Fertility Decline Editorial: Report and in Bangladesh: Toward an United Nations. 2013. World Commentary From Madrid: Understanding of Major Causes.” The Population Prospects: The United Nations World Health Transition Review, 2012 Revision . United Nations Journal Assembly on Ageing.” Supplement 6: 155–167. Population Division of the of Gerontology: Medical Sciences Department of Economic and 57/12: M770-M771. Kinsella, Kevin and Wan He. Social Affairs. 2009. An Aging World: Canning, David. 2011. “The U.S. Census Bureau. 2013. . International Population 2008 Causes and Consequences of International Data Base . Reports, P95/09-1, U.S. Census the Demographic Transition.” Available at , Working Paper 79. Kinsella, Kevin and Yvonne J. accessed between January and Gist. 1995. Older Workers, November 2014. Cleland, John, James F. Phillips, Retirement, and Pensions: Sajeda Amin, and G. M. Kamal. 2014 National _____. 2014. A Comparative International 1994. “The Determinants Projections . Available at Chartbook . IPC/95-2, of Reproductive Change in , accessed on Office. Washington, DC: The World Bank. December 11, 2014. Livingston, Gretchen and D’Vera Ezeh, Alex C., Blessing U. Mberu, U.S. Birth Rate Cohn. 2012. and Jacques O. Emina. 2009. Falls to a Record Low; Decline “Stall in Fertility Decline in Is Greatest Among Immigrants . Eastern African Countries: Pew Research Center, Social & Regional analysis of patterns, Demographic Trends. determinants, and implications.” Philosophical Transactions of the Meyer, Julie. 2012. Centenarians: 364: 2991–3007. Royal Society B 2010 . 2010 Census Special Reports, C2010SR-03, U.S. Census Bureau. Washington, DC: U.S. Government Printing Office. 13 An Aging World: 2015 U.S. Census Bureau

24

25 CHAPTER 3. The Dynamics of Population Aging Population aging can be measured In many countries today, the total men (both at birth and at older by various indicators. The primary fertility rate (TFR) has fallen below ages), the sex ratio (the number and most commonly used marker is the 2.1 children that a couple needs of males per 100 females) of the 1 In 2015, the proportion of the older popula- to replace themselves. older population is often skewed the TFR is near or below replace- tion in a society, with population toward females. This results in a ment level in all world regions but aging defined as an increasing demographic phenomenon referred Africa (Figure 3-1). The more devel- proportion of older people within to as the excess of women, which oped countries in Europe, where the age structure as discussed in could have significant implications fertility reduction started more the previous chapter. in providing for old age care. than 100 years ago, have had TFR Another indicator of population TOTAL FERTILITY RATES levels below replacement rate since aging is the median age, the age HAVE DROPPED TO OR the 1970s. Currently, the average that divides a population into UNDER REPLACEMENT TFR for Europe is a very low 1.6. numerically equal parts of younger LEVEL IN ALL WORLD Interestingly, the downward trend and older people. As population REGIONS BUT AFRICA in the TFR throughout Europe has aging progresses, the median age recently reversed in a number of The main demographic force rises. Population aging’s effect on countries, although the TFR still behind population aging is declin- a country’s societal support burden remains well below replacement. ing fertility rates. Populations with is often measured by the older high fertility tend to have a young dependency ratio, the ratio of the - age distribution with a high propor older population to the working- 1 The total fertility rate (TFR) is defined as - tion of children and a low propor age population. the average number of children that would be tion of older people, while those born per woman if all women lived to the end of their childbearing years and bore children Owing to the longer life expec- with low fertility have the opposite, according to a given set of age-specific tancy of women compared with resulting in an older society. fertility rates. Figure 3-1. Total Fertility Rate by Region: 2015, 2030, and 2050 2015 2030 2050 4.4 3.5 2.8 2.2 2.1 2.1 2.0 2.0 2.0 2.0 2.0 1.9 1.9 1.8 1.8 1.7 1.6 1.6 Latin America Northern Europe Asia Africa Oceania America and the Caribbean Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 15 U.S. Census Bureau

26 Box 3-1. China's One-Child Policy and Population Aging In the early 1970s, China began to institute fertility restrictions out of concern that rapid population growth would derail its development. A group of policies known as “later-longer-fewer” was designed to encourage delayed childbearing after marriage, longer intervals between births, and fewer births overall. Under these policies, China’s fertility fell dramatically from over 5 births per woman in 1972 to under 3 by 1977, the fast- est decline ever recorded, although declines varied by province (Tien, 1984). China introduced an even stricter policy in 1979 requiring most parents to have only one child. In 1984, due to strong son preference, most rural couples with a first-born daughter were permitted to have a second child. In 1991, China’s fertility fell below 2 children per woman, and since 2000 it has hovered around 1.5 (U.S. Census Bureau, 2013). What effect have China’s birth planning policies had on population structure and aging? Experts seem unani - mous in concluding that the “later-longer-fewer” campaign of the 1970s resulted in faster fertility declines than would have occurred in the absence of these policies. The exact impact depends on counterfactual assumptions of what policies might have otherwise been in place as well as the pattern of fertility decline that might have occurred under them (Goodkind, 1992; Wang, Cai, and Gu, 2012). Opinions are more divided about the extent to which birth restrictions are responsible for the pace of China’s fertility decline from the 1980s forward. Many experts in recent years argue that China’s fertility is very low due primarily to improved socioeconomic conditions and that fertility restrictions are increasingly irrelevant for childbearing decisions (e.g., Cai, 2010). Whatever the exact number of averted births, the impact of low fertility on China’s population may be understood by looking at its age-sex pyramids in 2015 and 2050 (Figure 3-2). The size of each birth cohort is determined by two factors—fertility rates at the time of birth and the number of females at childbearing ages. The notable constriction of the 2015 population pyramid for the age groups 30 to 34 and 35 to 39 corresponds to the cohort born during the “later-longer-fewer” era of the 1970s and after the one-child policy was instituted in 1979. The subsequent enlargement of younger cohorts (peaking at ages 25–29) is an “echo” of the large number of females born in the late 1960s, which likely counterbalanced the reduction in fertility caused by the one-child policy. In 2050, the population pyramid reflects the longer term effects of China’s declining fertility. The echo generation will be approaching older ages (60 to 64). Age groups older than 60 will likely form a heavy top for China’s age distribution. As the smaller birth cohorts of the 1990s and 2000s reach prime working ages, China will experience a shrinking labor force. By 2050, the population in the primary working ages, 20 to 59, is projected to represent only 46.5 percent of the total population, down from the peak of 61.6 percent in 2011. Note: The primary working ages 20 to 59 are used in this discussion because China’s mandatory retirement ages for the majority of salaried workers are 60 for men and 55 for women, except for government officials or workers in heavy or hazardous industries. Continued on next page. An Aging World: 2015 U.S. Census Bureau 16

27 Figure 3-2. Population by Age and Sex for China: 2015 and 2050 2015 2050 80 and over 80 and over 75 to 79 75 to 79 Male Male Female Female 70 to 74 70 to 74 65 to 69 65 to 69 60 to 64 60 to 64 55 to 59 55 to 59 50 to 54 50 to 54 45 to 49 45 to 49 40 to 44 40 to 44 35 to 39 35 to 39 30 to 34 30 to 34 25 to 29 25 to 29 20 to 24 20 to 24 15 to 19 15 to 19 10 to 14 10 to 14 5 to 9 5 to 9 0 to 4 0 to 4 60 80 0 40 20 60 0 20 40 80 20 80 80 60 40 20 60 40 Millions Millions Source: U.S. Census Bureau, 2013; International Data Base. Many less developed countries it is projected that the decline countries are projected to have in Asia and Latin America, on the will continue over the next 35 fertility rates at or below 2.1. This other hand, have experienced more years through 2050, albeit at a would be a significant achievement recent and rapid fertility declines slower pace. in Latin America’s fertility transi- than Europe. Overall TFR levels in tion, regardless of each country’s While the average TFR for Latin Asia and Latin America decreased development level today. America is 2.1, the majority of by about 50 percent (from 6 to 3 Asia’s current low regional TFR is countries in the region have below children per woman) during the - particularly impressive, consider replacement fertility rates as of period 1965 to 1995 (Kinsella and ing that there are still some Asian 2015, with Cuba (1.5) and Brazil - He, 2009). As of 2015, the aver countries with quite high 2015 (1.8) having the lowest fertility age TFR for both regions is at the fertility levels, such as Afghanistan levels. By 2050, all Latin American replacement level of 2.1, and 17 An Aging World: 2015 U.S. Census Bureau

28 (5.3), Yemen (3.9), Iraq (3.3), and Africa’s fertility decline will con- African societies, the pervasive the Philippines (3.0). These high tinue into the middle of the cen- fertility control regime focused on fertility rates are offset by excep- tury. However, it is projected that postponement but not stopping, tionally low fertility in countries by 2050, two-thirds of African and unmet need for family planning such as Taiwan (1.1), Hong Kong countries will still have a TFR (Moultrie, Sayi, and Timaeus, 2012; (1.2), South Korea (1.3), Japan higher than 2.1. Demographers Bongaarts and Casterline, 2013; (1.4), Thailand (1.5), and China (Caldwell, Orubuloye, and Caldwell, Casterline and El-Zeini, 2014). (1.6). By 2050, all 52 Asian coun- 1992) point out the different path Among African countries that are tries are projected to have below of fertility transition followed in projected to have the highest TFRs replacement fertility rates except Africa (“African exceptionalism”) in 2015, 2030, and 2050 (Table Afghanistan (2.8), Jordan (2.5), compared with the rest of the 3-1) are some populous African Philippines (2.2), and Timor-Leste world. They posit that the slow countries. The 11th-ranked TFR (2.2). fertility decline in Africa is the in 2015 is Nigeria, Africa’s most result of the still high ideal family populous country, which has a total FERTILITY DECLINES IN size, stemming from the distinc- population of 181.6 million in 2015 AFRICA BUT MAJORITY OF tive pronatalist cultural norms of and a projected 391.3 million in AFRICAN COUNTRIES STILL HAVE ABOVE REPLACEMENT Table 3-1. LEVEL FERTILITY IN 2050 Ten Lowest and Highest Total Fertility Rates for African Africa’s current regional TFR stands Countries: 2015, 2030, and 2050 at 4.4, more than twice the replace- 2050 2015 2030 ment level. Nevertheless, Africa 1.8 ... ... 1.7 Mauritius 1.7 ... Mauritius Mauritius has experienced fertility decline in Tunisia ... ... 1.8 ... Namibia 1.7 2.0 Namibia the last 15 years. At the turn of the Libya Tunisia ... 1.9 Tunisia ... 1.7 ... 2.1 Morocco Algeria Libya ... 2.0 1.9 ... 2.1 ... twenty-first century, two-thirds (34) Namibia 2.0 2.2 Morocco ... 2.0 Kenya ... ... of African countries had a TFR at South Africa 2.2 South Africa ... 2.0 ... ... Libya 2.0 or above 5, with the TFR exceed- Cabo Verde 2.1 ... Morocco ... 2.3 Botswana 2.0 ... Botswana ... 2.0 ... 2.1 South Africa Kenya 2.3 ... ing 7 in a few of these countries Lesotho Algeria 2.7 ... 2.0 2.2 ... Botswana ... (Uganda, 7.1; Somalia and Mali, Algeria ... 2.8 Swaziland ... 2.2 Swaziland ... 2.0 7.2; Niger, 8.0). In 2015, 15 years Nigeria Mozambique ... 5.2 3.1 ... 4.3 Tanzania ... later, the fertility decline has South Sudan 4.3 3.3 ... Nigeria ... ... Mali 5.3 reduced the number of countries Angola ... 5.4 Mozambique ... 4.4 Gabon ... 3.3 with above 5 TFR to 13, and 22 Zambia ... 4.5 Angola ... 3.5 ... 5.7 Angola other countries have a TFR between Burkina Faso 5.9 ... 4.5 Mozambique ... 3.5 ... Uganda Uganda 5.9 Somalia ... 4.5 Rwanda ... 3.5 ... 4 and 5. In another 15 years, 2030, Somalia ... 3.5 Burkina Faso 4.7 Niger 6.0 ... ... it is projected that only Burundi will Mali 3.6 ... 6.1 Burkina Faso ... 4.8 Sierra Leone ... maintain a fertility level above 5 Burundi 3.9 ... ... Zambia 5.0 6.1 Zambia ... Niger Burundi 4.1 ... ... 6.8 ... Burundi 5.3 and the number of countries with Notes: Total fertility rate is the average number of children that would be born per woman if all women a TFR between 4 and 5 will decline lived to the end of their childbearing years and bore children according to a given set of age-specific fertility to 14. rates. The list includes countries with a total population of at least 1 million in 2015. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 eau U.S. Census Bur 18

29 2050. Some other populous African Figure 3-3. countries with fertility rates pro - Population by Age and Sex for Nigeria: 2015 and 2050 jected to continue to be high are Male 2050 Male 2015 Female 2015 Female 2050 80 Ethiopia, 99.5 million in 2015 and and over 228.1 million in 2050; Tanzania, 75 51.0 million in 2015 and 118.6 70 million in 2050; and Mozambique, 25.3 million in 2015 and 59.0 mil - 65 lion in 2050. 60 55 Compared with the rest of the - world, the slow fertility transi 50 tion and above-replacement level 45 fertility in Africa will bring about 40 sustained population growth and 35 a corresponding slow pace of 30 population aging in most of the region, especially in Sub-Saharan 25 Africa. The age structure of most 20 Sub-Saharan African countries may 15 continue to be that of the tradi - 10 tional pyramid shape (see Figure 5 3-3 for the population distribution by age and sex in 2015 and 2050 0 6 0 2 4 4 2 6 for Nigeria, an African society Millions with high fertility levels). With the Source: U.S. Census Bureau, 2013; International Data Base. fertility transition only in the early stages in most Sub-Saharan coun - Figure 3-4. tries, population aging in Africa is Population by Age and Sex for Kenya: 2015 and 2050 only on the far horizon. Male 2050 Male 2015 Female 2015 Female 2050 80 It is worth noting that the cur - and over rent relatively high fertility levels 75 in many African countries could 70 also produce a sizable working 65 age population in 2050 (see Figure 60 - 3-4 for an example). If the fertil ity decline accelerated, then the 55 proportion of the population in 50 - the working ages could rise rela 45 tive to 2015 and result in lower 40 dependency ratios (see discussion 35 30 25 20 15 10 5 0 0.8 0.6 0.2 0.4 0 0.4 0.2 0.6 0.8 Millions Source: U.S. Census Bureau, 2013; International Data Base. U.S. Census Bureau An Aging World: 2015 19

30 Box 3-2. Support of Childless Older People in an Aging Europe By Martina Brandt, TU Dortmund University, and Christian Deindl, University of Cologne Western societies tend to have the highest proportion of older people (Kinsella and He, 2009) and are facing considerable pressure on pension and health systems, including services and financial resources for old age care (Börsch-Supan and Ludwig, 2010). An important aspect for old age support is who will provide the care, especially Figure 3-5. Percentage Distribution of Population Aged 50 and Over by Number of Surviving Children for Selected European Countries: 2006–2007 4 5 or more 0 1 2 3 Austria Belgium Czech Republic Denmark France Germany Greece Ireland Italy Netherlands Poland Spain Sweden Switzerland 40 0 100 80 60 20 Percent Note: The population with 0 surviving children includes those who never had any children and those who have outlived their children. Source: Survey of Health, Ageing, and Retirement in Europe, release 2.5.0, May 2011. Continued on next page. An Aging World: 2015 U.S. Census Bureau 20

31 for those who are very old and have no partners. Traditionally, children are the mainstay of old age support, espe - cially when only one parent is still living. However, people are not only living longer but also having fewer children, with rising childlessness among the older people (Albertini and Mencarini, 2014; Hayford, 2013; Rowland, 2007). Thus new challenges arise: Who will provide help and care to the childless older people? On what support networks can they rely? And, what role does the state play in care provision? Today about 10 percent of the population aged 50 and over in Europe are childless, according to data from the Survey of Health, Ageing, and Retirement in Europe (see Börsch-Supan et al., 2011 for details), ranging from 5 to 15 percent in individual countries (Figure 3-5; also see Hank and Wagner, 2013). Childless elders in this study are defined as those who never had any children and those who have outlived their children (3 percent of the childless people aged 50 and older). Family and intergenerational relations play an important role for support in old age. Older parents in need typically receive the most help from their children. In the absence of children, vital support for older persons has been taken over by public providers in many countries in Europe. In countries with low social service provision such as Italy, Spain, and Poland, older people are thus likely to experience a lack of help (Deindl and Brandt, 2011), especially when childless and dependent on care. Childless elders also often receive care by extended family, friends, and neighbors (Deindl and Brandt, 2014). Compared with those who have children, childless older people in need of care (with at least one limitation in instrumental activities of daily living) are more likely to receive any support (Figure 3-6). With regard to the type of support (formal, informal, or both), childless older people are Figure 3-6. more likely than their counterparts Type of Support Received by People Aged 50 and to receive formal and combined Over in Selected European Countries by Child Status: support. Older parents, however, 2006–2007 on average receive more help (In percent) hours from their children and their broader social network such 56.7 as family, friends, and neighbors None (Deindl and Brandt, 2014). 64.7 The provision of formal care is of great importance not only for 22.5 Informal childless older people but also 23.0 for older parents whose children Childless live far away. It will likely become Have children even more important in the future 10.1 Formal - when the number of available fam 6.2 ily helpers is expected to further decline, due to fewer siblings and 10.8 children and greater living dis - Both tances between family members. 6.2 In developed welfare states, social networks and services work hand Notes: This figure includes only older people with limitations in Activities of Daily Living in hand, and likely leading to a (ADL) and Instrumental Activities of Daily Living (IADL). higher quantity and better quality Aggregate data are based on the following countries: Austria, Belgium, Czech Republic, of support for older people without Denmark, France, Germany, Greece, Italy, Netherlands, Spain, Sweden, and Switzerland. Source: Survey of Health, Ageing, and Retirement in Europe, release 2.5.0, May 2011. children who are especially depen - dent on formal care arrangements. An Aging World: 2015 21 U.S. Census Bureau

32 on dependency ratios later in this chapter), potentially enabling Figure 3-7. demographic dividends in the Countries With Expected Decline of at Least 1 Million next few decades for many African in Total Population From 2015 to 2050 2 (Numbers in millions) However, demographers countries. and economists warn that Sub- –57.8 China Saharan Africa’s continued rapid (–4.2%) increase of children may translate –19.7 (–15.5%) Japan into a large number of unemployed –12.5 (–8.8%) youth, hindering economic devel- Russia opment with an adverse impact –10.4 (–23.7%) Ukraine on food security and sustainability of natural resources (Sippel et al., –9.3 (–11.5%) Germany 2011; African Development Bank –6.2 (–16.2%) Poland Group, 2012; Drummond, Thakoor, 3 and Yu, 2014). South –5.7 (–11.7%) Korea SOME COUNTRIES TO –3.6 (–16.6%) Romania EXPERIENCE SIMULTANEOUS –2.6 (–11.0%) POPULATION AGING AND Taiwan POPULATION DECLINE –2.2 (–32.3%) Bulgaria European demographers have –1.9 (–2.8%) Thailand warned for decades about the possibility of declining total –1.9 (–17.0%) Cuba population size accompanying population aging in some European –1.4 (–14.2%) Hungary countries, due to their persistent –1.3 (–18.2%) Serbia “lowest-low fertility” levels (Kohler, Billari, and Ortega, 2002). In –1.3 (–36.2%) Moldova some European countries, such as –1.3 (–13.0%) Belarus, Bulgaria, Romania, Serbia, Belarus and Ukraine, population decline Note: Percentage decline is shown in parentheses. started 2 decades ago. Source: U.S. Census Bureau, 2013; International Data Base. Interestingly, a list of countries projected to experience a popula- tion decline of at least 1 million compiled by Kinsella and He (2009, due to HIV/AIDS has changed the 2 Figure 3-3) in 2008 differs some- prospects for South Africa and Demographic dividend refers to accelerated economic growth as a result of what from the same list compiled removed it from the list. Italy and fertility and mortality declines and subse- in 2015 (Figure 3-7). Four countries Spain have dropped off the list pri- quent lower dependency ratios. For more information on the demographic dividend, included in the earlier list are no marily due to increases in fertility see Bloom, Canning, and Sevilla, 2003. 3 longer projected to face a sub- and major immigration flows. Italy’s For more discussion on possible overestimates of the pace of Sub-Saharan stantial population decline—South total population is still projected to Africa’s future fertility decline, and thus Africa, Italy, Spain, and the Czech decline but only by 0.4 million underestimates of the growth of children, see Eastwood and Lipton (2011) and Republic. Decreases in mortality by 2050. UNICEF (2014). An Aging World: 2015 eau U.S. Census Bur 22

33 New countries joining the list supply of caregivers and the poten- from 114 in 1980 to 59 in 2015, include China, South Korea, tial demand for care (number of while the older dependency ratio Thailand, Cuba, Hungary, Serbia, care recipients). However, not all increased slightly from a mere 7 to and Moldova. The addition of the individuals who fall in a certain age 11 over the same period, provid- three Asian countries is being category are actually “dependents” ing an ideal opportunity to reap the driven by rapid decreases in their or “providers”—some older (or demographic dividend. However, fertility rates. It is important to younger) people work or have the looking forward, while Indonesia’s bear in mind that the projected financial resources to be indepen- total dependency ratio is projected decline in total population in these dent and some in the “working to increase just slightly to 74 in Asian countries will be accompa- ages” do not work. 2050, the contributing factors will nied by the rapid expansion of their be shifted due to both ongoing The total dependency ratio for the older population. The demographic fertility decline and increasing life world in 2015 is 73, indicating that phenomenon of simultaneous expectancy. By 2050, the youth every 100 people aged 20 to 64 population aging and population dependency ratio will decrease are supporting 73 youth and older decline, originally projected to further to 41 and the older depen- people combined (Figure 3-8). The occur only in European countries, is dency ratio will rise sharply to 33. world’s total dependency ratio is now spreading to Asia. not expected to rise very much in Zambia, on the other hand, pres- the next few decades, reaching 78 ents a sharp contrast in the level COMPOSITION OF in 2050. However, the composi- and trend of its total dependency DEPENDENCY RATIO tion of the total dependency ratio ratio. Zambia’s total dependency WILL CONTINUE TO will change considerably—in 2015, ratio was at a much higher level SHIFT TOWARD OLDER there are 15 older people and 59 in 1980 (165) and is projected to DEPENDENCY youth per 100 working age people, decline at a slower rate than the The total dependency ratio is the and by 2050 the older dependency trajectory for Indonesia (Figure sum of the older dependency ratio ratio is projected to double to 30 3-9). By 2050, the total dependency and the youth dependency ratio. and the youth dependency ratio to ratio in Zambia is projected to The older dependency ratio in this decline to 48 per 100 working age remain over 100 (at 116), indicat- report is defined as the number of people. Youth will still account for ing that the dependent population people aged 65 and over per 100 the majority of all dependents, but of youth and older people will people of working ages 20 to 64, the older share is rising. continue to exceed the size of the and the youth dependency ratio is working age population. The com- Countries vary drastically in their the number of people aged 0 to 19 position of the total dependency total dependency ratio composi- per 100 people aged 20 to 64. The ratio in Zambia changes very little tion, largely due to differences in working ages of 20 to 64 are used from 1980 to 2050. Fertility decline their stages of fertility and mortal- here with the acknowledgment that lowers the youth dependency ratio ity decline. Indonesia, for example world regions and countries differ from 159 in 1980 to 140 in 2015 (Figure 3-9), experienced a nearly vastly in youngest working age and and to 109 in 2050, while the older 50 percent reduction in the total retirement age. dependency ratio remains almost dependency ratio from 1980 (121) constant at an extremely low level Dependency ratios provide a gross to 2015 (70), due in large mea- of about 6 to 7. Even by the middle estimate of the pressure on the sure to a sharp fertility decline - of the twenty-first century, popula productive population, and offer an and corresponding decrease in tion aging will not have material- indication of a society’s caregiving the youth dependency ratio. The ized in Zambia. burden by estimating the potential youth dependency ratio dropped 23 An Aging World: 2015 U.S. Census Bureau

34 Figure 3-8. Youth dependency ratio Dependency Ratios for the World: 2015 to 2050 Older dependency ratio 100 80 60 40 20 0 2015 2050 2045 2040 2035 2030 2025 2020 Note: The older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64. The youth dependency ratio is the number of people aged 0 to 19 per 100 people aged 20 to 64. Source: U.S. Census Bureau, 2013; International Data Base. Figure 3-9. Dependency Ratios for Indonesia and Zambia: 1980, 2015, and 2050 Youth dependency ratio Older dependency ratio Zambia Indonesia 180 180 160 160 140 140 120 120 100 100 80 80 60 60 40 40 20 20 0 0 2050 2015 1980 2050 1980 2015 Note: The older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64. The youth dependency ratio is the number of people aged 0 to 19 per 100 people aged 20 to 64. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 eau U.S. Census Bur 24

35 half of the population in these Japan will be at or near the ages for MEDIAN AGES FOR countries are children under age the older population. Obviously the COUNTRIES RANGE FROM 18. Furthermore, African coun- allocation of resources in countries 15 TO NEAR 50 tries with sustained high fertility with drastically different median Another way to measure popula- are expected to have very young ages will diverge significantly. tion aging is to consider a coun- median ages even by 2050 (e.g., try’s median age, the age that As expected, older regions have a Zambia, 20). divides a population into numeri- higher median age and vice versa cally equal shares of younger and At the other end of the spectrum (Table 3-2). However, an interesting older people. African countries are Japan and Germany with a observation is the variation in the are among the youngest, with current median age of 47. It is median age by sex differentials, relatively low median ages. For projected that Japan’s median age reflecting the differences in mortal- example, Niger, Uganda, and Mali will reach 53 by 2030 and 56 by ity and life expectancy by sex in have current median ages of about 2050—half of the population in different regions. While women in 15 to 16 (Figure 3-10)—more than Figure 3-10. Countries With Lowest or Highest Median Age in 2015: 2015, 2030, and 2050 2015 2030 2050 Years 60 50 40 30 20 10 0 Uganda Italy Slovenia Greece Mozambique Zambia Mali Germany Niger Japan Note: Median age for the years 2015, 2030, and 2050 is shown for the five countries with the lowest and highest median age as of 2015. Source: U.S. Census Bureau, 2013; International Data Base. Table 3-2. Median Age by Sex and Region: 2015, 2030, and 2050 (In years) Both sexes Female Male Region 2030 2050 2015 2030 2050 2015 2030 2050 2015 26.4 ... 19.7 22.0 26.0 19.4 21.7 25.6 19.9 22.3 Africa Asia ... 30.6 35.7 40.5 29.9 34.9 39.6 31.3 36.6 41.5 Europe 47.2 45.3 49.6 ... 41.6 43.4 47.1 39.7 43.4 44.8 Latin America and the Caribbean 33.3 29.1 34.4 40.6 28.2 ... 39.2 30.0 35.5 42.1 Northern America 38.1 ... 40.0 41.1 36.8 38.8 39.8 39.5 41.3 42.4 Oceania 37.5 41.0 34.6 ... 34.0 36.8 40.0 33.5 36.1 39.1 Source: U.S. Census Bureau, 2013; International Data Base. 25 An Aging World: 2015 U.S. Census Bureau

36 equally young, with a differential of all regions have older median ages outnumber younger females, but less than 1 year in median age for than men, the female-male gap thanks to the female advantage in life expectancy at birth and at older 2015, 2030, and 2050. is currently and projected to be ages, older women outnumber largest in the oldest region, Europe SEX RATIOS AT OLDER AGES older men, as illustrated in Figure (3.7 in 2015 and 4.8 in 2050). The 4 RANGE FROM LESS THAN 50 higher proportion of women among 3-11 for the United States. TO OVER 100 the older population combined At older ages, the sex ratio with a larger number of older Sex ratio is defined as the number decreases with increasing age people result in a European society of males for every 100 females. It (Figure 3-12). Globally, the total with many more older and old - - is a common measure of a popu number of males slightly exceeds est women than men. In contrast, lation’s gender composition with in the youngest region of Africa, implications for social support 4 See Chapter 4 for more information on males and females are almost needs. In general, younger males sex differentials in life expectancy. Figure 3-11. Difference Between Female and Male Populations by Age in the United States: 2010 Age 85 and over 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 More male More female 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 1.0 0.0 0.5 0.5 1.0 1.5 1.5 2.0 2.0 Millions Source: U.S. Census Bureau, 2011; 2010 Census. An Aging World: 2015 U.S. Census Bureau 26

37 Sex ratios vary greatly by region the number of females in 2015, combat cohort reached the older age ranks, a reflection of the devas with a sex ratio of 101.4. However, and country (see Appendix B, Table - by age 65 and older, the sex ratio tating male casualties in the war for B-4). While the vast majority of these former Soviet Union countries - is only 80.3. The sex ratio contin countries have a sex ratio below (Vassin, 1996; Heleniak, 2014). ues to decline steadily for older 100 for their older population, age groups. For example, there are Russia and some other Eastern Russia’s sex ratio for the older - European countries have unusu only half as many men as women population in 1990 was a very in the world in the age group 85 ally low sex ratios (e.g., in 2015, low 35.8. It climbed up to the 40s Belarus, 46.4; Latvia, 48.5; Ukraine, and over. The sex ratio drops to a by the mid-1990s and remained 48.9; and Estonia, 49.8). These low of 22.5 for people aged 100 steady throughout the 2000s and and over, indicating that for every exceptionally low sex ratios for 2010s, and is at 44.6 in 2015. It the older population started in the male centenarian, there are over 4 is projected that Russia’s sex ratio female counterparts. late 1980s when the World War II will not rise above 50 until the Figure 3-12. Sex Ratio for World Total Population and Older Age Groups: 2015 101.4 80.3 74.9 68.4 60.5 50.6 39.6 30.1 22.5 95+ 65+ 80+ 85+ 90+ 75+ 100+ Total 70+ Note: Sex ratio is number of men per 100 women. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 27 U.S. Census Bureau

38 mid-2020s and will remain at that high sex ratios are projected to ratio at older ages could persist level through 2050 (Figure 3-13). decline only slightly through 2050. due to the introduction of prenatal With the passage of the World War For example, Bangladesh’s sex diagnosis technology around 1980. II cohort, the main contributors to ratio for the population aged 65 The available technology com- the low sex ratio in Russia in recent and over in 1990 was 111.9. It bined with traditional patriarchal years have been high male midlife stayed over 100 until 1999, and cultural norms of son preference mortality from various diseases is projected to remain over 90 led to unusually high sex ratios at such as cardiovascular disease as until 2029 (Figure 3-13). By 2050, birth in several countries, includ- well as violence, accidents, and Bangladesh’s sex ratio for the older ing China, India, and South Korea. alcohol-related causes (Oksuzyan et population likely will be about 87. While concerns have been raised al., 2014). about “an irreversible demographic The excess male sex imbalance masculinization” (Guilmoto, 2012), An opposite and also unusual pat- in older ages, found primarily in South Korea may lead a new trend tern for sex ratios is found in parts parts of Asia, is often referred to for reversing the distorted sex ratio of Asia and Sub-Saharan Africa—the as “missing women.” This phenom- at birth—the sex ratio at birth in sex ratios for the older popula- enon is believed to be the result of South Korea has been declining tion are as high as 90 or even long standing female disadvantage - from the mid-1990s. Son prefer above 100 (e.g., in 2015, India, in health and nutrition, leading ence in the country has decreased, 90.1; Malaysia, 90.3; China, 91.9; to higher female infant and child impacted by normative changes Bangladesh, 96.7; Mali, 100.0; - mortality in addition to mater in desired family size triggered by Niger, 103.6; Bhutan, 109.9; and nal mortality (Sen, 1990; 2001). social and economic development Sudan, 119.4). These remarkably Looking forward, the distorted sex (Chung and Das Gupta, 2007). Figure 3-13. Sex Ratios for Population Aged 65 and Over for Bangladesh and Russia: 1990 to 2050 120 100 Bangladesh 80 60 Russia 40 20 0 2050 1995 2010 2015 2020 2025 2030 2035 2040 2045 2000 2005 1990 Note: Sex ratio is number of men per 100 women. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 eau U.S. Census Bur 28

39 Chapter 3 References Caldwell, John C., I. Olatunji Goodkind, Daniel. 1992. Estimates Orubuloye, and Pat Calwell. of Averted Chinese Births, African Development Bank Group. 1992. “Fertility Decline in Africa: 1971-1990: Comparisons of 2012. “Africa’s Demographic A New Type of Transition?” Fertility Decline, Family Planning Trends.” Briefing Notes for Population and Development Policy, and Development in Six AfDB’s Long-Term Strategy, Review 18/2: 211–242. . Australian Confucian Societies Briefing Note 4. National University Working Casterline, John B. and Laila O. Paper in Demography 38. Albertini, Marco and Letizia El-Zeini. 2014. “Unmet Need and Canberra: Research School Mencarini. 2014. “Childlessness Fertility Decline: A Comparative of Social Sciences, Australian and Support Networks in Later Perspective on Prospects in National University. Life: New Pressures on Familistic Studies in Sub-Saharan Africa.” Welfare States?” Journal of Family Planning 45/2: 227–245. Sex Guilmoto, Christophe Z. 2012. Family Issues 35/3: 331–357. Imbalances at Birth: Current Chung, Woojin and Monica Das Trends, Consequences and Policy Bloom, David E., David Canning, Gupta. 2007. “The Decline of . Bangkok, Thailand: Implications The and Jaypee Sevilla. 2003. Son Preference in South Korea: UNFPA Asia and the Pacific Demographic Dividend: A New The Roles of Development and Regional Office. Perspective on the Economic Public Policy.” Population and Consequences of Population 33/4: Development Review Hank, Karsten and Michael Wagner. Change . Santa Monica, CA: 757–783. 2013. “Parenthood, Marital RAND. Status, and Well-Being in Later Deindl, Christian and Martina Life: Evidence from SHARE.” Bongaarts, John and John Brandt. 2011. “Financial Support Social Indicators Research Casterline. 2013. “Fertility and Practical Help Between 114/2: 639–653. Transition: Is Sub-Saharan Africa Older Parents and Their Middle- Different?” Population and Aged Children in Europe.” Hayford, Sarah R. 2013. “Marriage 38 Development Review Ageing & Society 31/4: 645–662. (Still) Matters: The Contribution /Supplement: 153–168. of Demographic Change to _____. 2014. “Support Networks Trends in Childlessness in the Börsch-Supan, Axel H. and of Childless Elders: Informal United States.” Demography Old Alexander Ludwig. 2010. and Formal Support in Europe.” 50/5: 1641–1661. Europe Ages: Reforms and Mimeo. . National Reform Backlashes Heleniak, Timothy. 2014. Bureau of Economic Research Drummond, Paulo, Vimal Thakoor, Census Atlas of Russia: Sex Working Paper 15744. Africa Rising: and Shu Yu. 2014. Composition, Age Structure,and Harnessing the Demographic Marital Status . Washington, DC: Börsch-Supan, Axel H., Martina . International Monetary Dividend National Council for Eurasian Brandt, Karsten Hank, and Fund Working Paper WP/14/143. and East European Research. Mathis Schroder (eds.). 2011. The Individual and the Welfare Eastwood, Robert and Michael . State: Life Histories in Europe Lipton. 2011. “Demographic Heidelberg, Germany: Springer. Transition in Sub-Saharan Africa: How Big Will the Economic Cai, Yong. 2010. “China’s Population Studies Dividend Be?” Below-Replacement Fertility: 65/1: 9–35. Government Policy or Socioeconomic Development?” Population and Development Review 36/3: 419–440. 29 An Aging World: 2015 U.S. Census Bureau

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41 CHAPTER 4. Life Expectancy, Health, and Mortality There is little doubt that popula- increasing longevity. Between 1990 reach older age healthier. However, tion aging will accelerate over the and 2013, the number of deaths the current evidence about whether from noncommunicable diseases coming decades, as outlined in older adult cohorts are physically (NCDs) has increased by 42 per - Chapter 2. The changed age struc- and cognitively healthier than cent; and the largest increases in tures in most parts of the world preceding generations is mixed the proportion of global deaths have contributed to a growing (Langa et al., 2008; Crimmins number of older people who may took place among the population and Beltran-Sanchez, 2011; Lin et aged 80 and over (Lozano et al., have various health conditions or al., 2012; Matthews et al., 2013; concerns about functioning in older 2012; GBD 2013 Mortality and Lowsky et al., 2014). Better health age. Understanding the differences Causes of Death Collaborators, for those reaching older age could in health status and well-being of 2015). An estimated 42.8 percent be realized through addressing of deaths worldwide occur in the older populations is essential not the social determinants of health, only to those who comprise this population aged 70 and over, with minimizing health risks, and recon- 22.9 percent in the population aged age group, but also for the social figuring health and social support 80 and over (Wang et al., 2012). and economic systems. Variations systems to maximize well-being within regions or between coun- in an aging population; and these Cardiovascular disease, lung tries help to identify the impact efforts could simultaneously sus- disease, cancer, and stroke are the of different policies and to plan tain the growth in life expectancy leading killers for the population for future health care services and seen since the mid-1800s and lead aged 60 and over; however, with a social support systems. to more rational use of resources few notable exceptions such as dia- (Brandt, Deindl, and Hank, 2012; betes and chronic kidney disease, Current questions about whether or Rizzuto et al., 2012; Bloom et not limits to human life span exist age-standardized rates for many of al., 2015; Kruk, Nigenda, and and whether healthy life expec- the leading NCDs have generally Knaul, 2015). tancy will keep pace with increas- declined. The drivers of mortality also vary considerably by region ing average life expectancy are just DEATHS FROM two of the scientific issues being and level of economic develop- NONCOMMUNICABLE robustly debated about our aging ment. The communicable disease DISEASES RISING burden is highest in the World world (Oeppen and Vaupel, 2002; The world average age of death Health Organization’s (WHO) Africa Olshansky et al., 2007, Sanderson has increased by 35 years since region, but also more broadly and Scherbov, 2010; Lee, 2011). 1970, with declines in death rates in low and lower-middle income A number of other related topics, in all age groups, including those including frailty, mild cognitive countries (Table 4-1). These same aged 60 and older (Institute for impairment, predisease thresholds, regions are also facing a significant Health Metrics and Evaluation, and premature death, are also burden from NCDs and injuries. 2013; Mathers et al., 2015). From Deaths and disability from NCDs generating considerable discussion. 1970 to 2010, the average age of The scientific outcomes of these are rapidly rising in less devel- death increased by 30 years in East oped countries and yielding worse debates have practical implications: Asia and 32 years in tropical Latin outcomes than in more developed the health levels among the grow- America, and in contrast, by less countries; some diseases that are ing number of older adults have than 10 years in western, south- preventable or treatable in more real and potentially significant cost ern, and central Sub-Saharan Africa developed countries are lead- considerations for health and pen- (Institute for Health Metrics and ing to deaths in less developed sion systems. 1 Evaluation, 2013; Figure 4-1). countries (Daniels, Donilon, and Despite considerable interest in the Bollyky, 2014). Age-standardized The leading causes of death negative impact of aging on popu- mortality rates due to communi- are shifting, in part because of lation health and public coffers, cable diseases in 2012 show a the contributions to society would clear gradient by country income 1 likely outweigh burdens if adults These geographic areas are defined by grouping. While these differences the World Health Organization. 31 An Aging World: 2015 U.S. Census Bureau

42 Figure 4-1. Mean Age of Death in Global Burden of Disease Regions: 1970 and 2010 Mean age at death in 1970 (years) 80 Western 70 Europe High-income North America Australasia Eastern Europe High-income Central Europe 60 Asia Pacific 50 Southern Latin America Central Asia 40 Caribbean East Asia Southern sub-Saharan Africa Southeast Asia Tropical Latin America Oceania 30 Central Latin America South Asia Andean Latin America Central sub-Saharan Africa North Africa and Middle East Eastern sub-Saharan Africa 20 Western sub-Saharan Africa 10 0 0 20 10 80 50 70 60 30 40 Mean age at death in 2010 (years) Source: Wang et al., 2012. Adapted from Figure 8. contribute to considerable changes Table 4-1. in the mean age at death between Age-Standardized Mortality Rates by Cause of Death, WHO 1970 and 2010 across different Region, and Income Group: 2012 WHO regions, all regions have had (Per 100,000 population) increases in mean age at death, Non- particularly East Asia and tropical communicable Communicable Characteristic Injuries diseases diseases Latin America (Figure 4-1). Global 178 ... 73 539 LIFE EXPECTANCY AT BIRTH WHO Region EXCEEDS 80 YEARS IN 24 Africa 116 652 ... 683 COUNTRIES WHILE IT IS Americas ... 63 437 62 South-East Asia ... 232 656 99 LESS THAN 60 YEARS IN 28 Europe ... 45 496 49 COUNTRIES Eastern Mediterranean ... 214 654 91 Western Pacific 499 ... 50 56 In July 2015, a woman in the United States celebrated her 116th birth- Income Group day, becoming the world’s oldest Low income 502 625 104 ... Lower-middle income 673 99 272 ... Guinness person according to the Upper-middle income 558 75 ... 59 World Records , following the death High income ... 44 397 34 of a 117-year-old woman from Note: Region refers to World Health Organization regional grouping. Income groupings refer to World Bank analytical income of economies for fiscal year 2014. Japan earlier in the year (Associated Source: World Health Organization, 2014. An Aging World: 2015 U.S. Census Bureau 32

43 Press, 2015). Increasing longevity Northern America currently has Singapore, projected to have life - the highest life expectancy at 79.9 around the globe is indeed remark expectancy exceeding 90 years years and is projected to continue able, but looking across countries (both sexes). to lead the world with an average reveals uneven progress in popula - At the other end of the spectrum, regional life expectancy of 84.1 tion health as demonstrated by the 28 countries have a life expec - - cross-country differences in aver years in 2050. The current life tancy at birth below 60 years in - expectancy for Africa is only 59.2 age life expectancy. Life expec 2015. Among the 28 countries, tancy at different ages for men years. However, Africa is expected 27 are in Africa and one is in Asia and women points to considerable to undergo major improvements in (Afghanistan). By 2050, all 28 health and AIDS-related mortality heterogeneity and plasticity of countries, except Botswana and in the next few decades and its life aging processes, but also extreme Namibia, are projected to have their variation and persistent inequality. expectancy in 2050 is projected life expectancy at birth increase by The very same factors correlated to be 71.0 years, narrowing the more than 10 years, with Lesotho with the dramatic drops in mortal - gap between Northern America (an impressive increase of 19.4 and Africa. ity in Western Europe and North years) and Mozambique (17.9 years America at the beginning of the increase) leading the way. As of 2015, 24 countries have a 1900s, namely water, sanitation, life expectancy at birth of 80 years and diet still contribute to mortality Women currently live longer than or longer. Japan, Singapore, and rates across many other regions— men on average in nearly all Macau lead this group with life although with considerable and countries. However, the female expectancy at birth exceeding 84 ongoing progress. advantage generally is narrower years (Table 4-3). Women born in (about 2 to 3 years currently) Global life expectancy at birth these countries today are expected among countries with the lowest reached 68.6 years in 2015 on average to live to about age - life expectancies at birth as com (Table 4-2). A female born today 88, compared with about age 82 pared to countries with the highest is expected to live 70.7 years on for men. In the next 35 years, life expectancies at birth (gaps of most of these 24 countries will average and a male 66.6 years. - about 5 to 6 years). Global mortal see an extension of 2 to 3 years in The global life expectancy at birth ity rates show a uniformly smaller their life expectancy at birth, with is projected to increase almost 8 percentage decline for men than the top two countries, Japan and years, reaching 76.2 years in 2050. women at all age groups, with the possible exception of men in the Table 4-2. 80 years and older age group Life Expectancy at Birth by Sex for World Regions: (Wang et al., 2012; GBD 2013 2015 and 2050 Mortality and Causes of Death Collaborators, 2015). This means Female Both sexes Male Region that the female mortality advantage 2015 2015 2050 2050 2015 2050 persists and is generally expanding 70.7 78.8 World ... 68.6 76.2 66.6 73.7 73.4 ... Africa 60.7 59.2 71.0 57.6 68.7 at the global level. Over time, the Asia ... 71.0 78.5 69.1 76.0 73.0 81.1 gender gap is expected to increase 81.1 78.8 73.7 82.1 77.3 ... Europe 85.5 in countries with the lowest life 83.5 .. 74.5 80.3 71.6 77.3 77.6 Latin America and the Caribbean Northern America ... 79.9 84.1 77.4 81.9 86.2 82.2 expectancies at birth (Table 4-3). 76.7 79.2 78.2 74.4 80.7 83.4 ... Oceania Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 33 U.S. Census Bureau

44 Table 4-3. Countries With Highest and Lowest Life Expectancy at Birth by Sex in 2015 and Projected for 2050 (In percent) Life expectancy at birth 2050 2015 Country Male Female Both sexes Male Female Both sexes 81.4 88.3 91.6 88.4 95.0 ... Japan 84.7 84.7 Singapore 87.5 91.6 88.7 94.6 ... 82.1 ... 81.6 87.6 85.1 82.2 88.1 Macau 84.5 82.9 80.2 85.8 84.4 81.6 87.4 Hong Kong ... ... 82.5 80.2 84.9 84.2 81.6 87.0 Switzerland ... Australia 84.7 84.1 81.4 86.9 82.2 79.7 82.1 81.3 84.9 84.1 ... 87.0 Italy 79.5 ... 80.1 84.0 84.0 81.5 86.6 Sweden 82.0 ... 81.8 79.2 84.5 83.9 81.1 86.8 Canada ... 78.7 85.0 83.9 80.9 87.0 81.8 France 83.8 81.7 79.7 Norway 83.9 81.4 86.5 . . . . . . . . . . . . . . . . . . . . . Spain ... 81.6 78.6 84.8 83.8 80.9 86.9 Israel ... 79.1 83.7 83.8 81.1 86.5 81.4 ... 79.1 83.5 83.7 81.1 86.4 Netherlands 81.2 ... 81.1 79.0 83.2 83.6 81.1 86.3 New Zealand Ireland ... 78.4 83.1 83.4 80.8 86.2 80.7 Germany 80.6 78.3 83.0 83.4 80.7 86.2 ... Jordan ... 80.5 79.1 82.1 83.4 81.1 85.8 United Kingdom ... 78.4 82.8 83.4 80.8 86.1 80.5 Greece 80.4 77.8 83.2 83.3 80.6 86.3 ... Austria ... 80.3 77.4 83.4 83.3 80.3 86.4 Belgium 80.1 76.9 83.4 83.2 80.1 86.3 ... 87.1 ... 80.0 77.0 83.3 84.2 81.5 South Korea 86.3 Taiwan ... 80.0 76.9 83.3 83.1 80.1 69.6 72.0 74.4 Rwanda ... 59.7 58.1 61.3 Congo (Brazzaville) ... 57.6 60.0 71.1 69.0 73.2 58.8 ... 58.6 60.3 70.7 68.3 73.2 Liberia 56.9 ... 57.2 59.5 69.7 68.0 71.4 Cote d’Ivoire 58.3 ... 57.9 56.6 59.3 Cameroon 69.7 74.4 72.0 Sierra Leone 57.8 55.2 60.4 70.2 67.1 73.3 ... ... 57.1 56.5 57.6 67.2 66.9 67.5 Zimbabwe Congo (Kinshasa) ... 56.9 55.4 58.5 70.2 67.8 72.7 Angola ... 54.5 56.8 69.2 67.1 71.5 55.6 ... 68.4 53.5 57.3 Mali 65.7 71.1 55.3 Burkina Faso 55.1 53.1 57.2 67.8 65.1 70.5 ... Niger ... 55.1 53.9 56.4 68.2 66.1 70.5 Uganda 54.9 53.5 56.4 67.8 65.6 70.0 ... 58.4 ... 54.2 56.0 52.3 61.6 64.8 Botswana ... Malawi 53.5 52.7 54.4 65.3 64.0 66.5 Nigeria ... 52.0 54.1 68.1 66.0 70.3 53.0 ... 52.9 53.0 72.3 71.5 73.2 Lesotho 52.8 ... 52.2 53.7 70.8 69.0 72.7 Mozambique 52.9 ... 52.2 50.5 53.8 Zambia 62.5 66.7 64.5 Gabon 52.0 51.6 52.5 62.1 61.6 62.6 ... ... 52.0 49.9 54.1 65.5 62.6 68.5 Somalia Central African Republic ... 51.8 50.5 53.2 65.5 63.5 67.7 Namibia ... 52.1 51.2 57.8 60.1 55.5 51.6 Swaziland 51.1 51.6 50.5 61.4 63.0 59.8 ... Afghanistan ... 50.9 49.5 52.3 64.5 62.2 66.9 Guinea-Bissau 50.2 48.2 52.3 63.5 61.0 66.2 ... 65.1 ... 49.8 48.6 51.0 63.4 61.7 Chad 64.1 62.3 48.7 South Africa ... 49.7 50.7 63.2 Note: Life expectancy at birth for 2015 and 2050 is shown for countries with the highest and lowest life expectancy at birth as of 2015. Source: U.S. Census Bureau, 2013; International Data Base. An Aging World: 2015 U.S. Census Bureau 34

45 rates are projected to improve to would live on average for about LIVING LONGER FROM AGE another 20 years, but older women 13.0 years and 15.0 years for men 65 AND AGE 80 and women, respectively. in these countries live on average Extension of life expectancy has about another 25 years (Figure also occurred at older ages. In the The largest gains in life expectancy 4-2). By 2050, the life expectancy United States, for example, life at age 60 have come from the for Japanese and Singaporean older expectancy at age 65 has increased reduction in cardiovascular disease men is projected to be about 25 from 11.9 years in 1900–1902 to and diabetes mortality (Figure 4-3). years and for older women about - 19.1 years in 2009. Life expec In high-income countries, reduc - 30 years. tancy at age 80 over the same time tion in cardiovascular disease and period also almost doubled from Countries with the lowest life diabetes mortality contributed a 5.3 years to 9.1 years (Arias, 2014). gain of 3.0 years in life expectancy expectancy at older ages are also for men and 4.3 years for women, projected to see improvement. - The female advantage in life expec and for men reductions in tobacco- Afghanistan, for example, has the tancy is also demonstrated at older lowest current life expectancy for caused mortality contributed to ages. In 2015, older men at age age 65, 11.0 years for men and another 2.0 years of gain in life 65 in Singapore, Macau, and Japan 12.1 for women. By 2050, these expectancy. On the other hand, an Figure 4-2. Countries With Highest and Lowest Life Expectancy at Age 65 by Sex: 2015 and 2050 (In years) Male Female 2015 25.2 24.9 24.5 22.5 22.4 20.6 20.2 20.0 19.0 19.0 13.1 12.8 12.9 12.8 12.1 11.7 11.7 11.7 11.4 11.0 Afghanistan Somalia Mali Burkina Guinea- Australia Singapore Macau Japan Switzerland Bissau Faso 2050 30.6 30.3 25.5 25.3 25.0 24.3 24.4 20.7 20.2 20.1 16.2 16.0 15.6 15.7 15.0 13.8 13.5 13.7 13.5 13.0 Singapore Switzerland South Japan Macau Guinea- Mali Chad Somalia Afghanistan Korea Bissau Note: Life expectancy estimates are derived from population estimates and projections produced for over 220 countries by the U.S. Census Bureau. For methodology, see . Source: U.S. Census Bureau, 2013; unpublished lifetables. An Aging World: 2015 35 U.S. Census Bureau

46 Figure 4-3. Drivers of Increase or Decrease in Life Expectancy at Age 60 by Sex, Region, and Income: 1980 to 2011 Years 6 Tobacco- attributable deaths 5 Communicable diseases Cancers 4 Cardiovascular disease and diabetes 3 Chronic respiratory 2 diseases Other noncommun- icable diseases 1 Injuries 0 Men Women Men Women Men Women –1 High-income Latin America and Middle-income countries the Caribbean countries of Europe Note: Tobacco-attributable deaths for specific disease causes are subtracted from the disease cause categories and shown as a single cause group. Thus, for example, the category labeled "Cancers" excludes tobacco-caused cancers. Source: Mathers et al., 2015. Adapted from Figure 2. increase in tobacco-related deaths disease morbidity and mortality in measure that also incorporates among women has limited their low- and middle-income countries functioning, disease, and ill health gains in life expectancy at age 60 may better describe population (Salomon et al., 2012). Meanwhile, - in high-income countries. Similar dementia and obesity are underly health across the life span. Healthy life expectancy (HALE) is one such patterns in cause-specific mortal - ing factors for the small losses ity reductions were found in the measure. in life expectancy and may limit middle-income countries in Latin progress in older age mortality in HALE takes into account both America and the Caribbean. the coming decades. mortality and morbidity and is described by the WHO as “the - The burden of simultaneous com YES, PEOPLE ARE LIVING municable and noncommunicable average number of years that a LONGER, BUT HOW MANY diseases, higher tobacco use, and person can expect to live in “full YEARS WILL BE LIVED IN lower effective health care cover health” by taking into account - GOOD HEALTH? “years lived in less than full health age has contributed to slower Life expectancy is a good summary improvements in older age mortal - due to disease and/or injury” measure of population mortality ity in middle-income countries than (World Health Organization, 2012). levels. Increasing life expectancy Among European countries in in high-income countries (Mathers at birth and at older ages suggests et al., 2015). However, aging 2012, French women had the healthier populations overall in populations and shifting infectious longest life expectancy at age 65, most countries. However, because disease epidemiology mean that 23.4 years (European Commission, of population aging and the accom - 2014; Figure 4-4). French men older adults are likely to account panying morbidity, a summary for a larger share of communicable were also among the highest in life An Aging World: 2015 U.S. Census Bureau 36

47 Figure 4-4. Life Expectancy (LE) and Healthy Life Years (HALE) at Age 65 by Sex for Selected European Countries: 2012 HALE HALE LE with activity limitations LE with activity limitations LE for men LE for women France Spain Switzerland Italy Finland Iceland Luxembourg Portugal Austria Belgium Germany Sweden Slovenia Ireland Norway Netherlands Malta Greece United Kingdom Estonia Denmark Poland Lithuania Czech Republic Croatia Slovakia Latvia Hungary Romania Bulgaria 5 25 20 15 10 25 10 15 20 5 0 Years Note: HALE is the average number of years that a person can expect to live in full health by taking into account years lived in less than full health due to disease and/or injury. Source: European Commission, 2014; Eurostat. An Aging World: 2015 37 U.S. Census Bureau

48 60 and over in Laos and 20 percent expectancy at age 65, 19.1 years. air pollution from solid fuels are of women aged 60 and over in the directly or indirectly responsible for However, Norway was at the top in 2012 for both men and women for a large share of the global burden Philippines (Byles et al., 2014). of disease (Lim et al., 2012). A healthy life expectancy. Norwegian - Both a history of obesity and cur women at age 65 were expected leading contributor to mortality rent obesity are important risk to live another 16 years without and morbidity, tobacco use has factors in mortality (Abdullah et al., activity limitations, and their male dropped dramatically in countries 2011; Flegal et al., 2013; Kramer, like the United States over the past counterparts 15.3 years. At the Zinman, and Retnakaran, 2013). In other end of the spectrum, some 3 decades. Yet an estimated 18 older ages, being underweight is percent of the general U.S. adult Eastern European countries had a - also associated with increased mor very short HALE. In Slovakia, for population still smoke (Colditz, tality (Population Reference Bureau, example, women aged 65 were 2015) and the long latency of 2007). The prevalence of obesity - expected to live just 3.1 years health consequences from smok has increased in the United States ing means that it is still playing without activity limitations and since the 1970s and accounts for out in current mortality rates in men 3.5 years. as much as 30 percent of the lower the United States and worldwide U.S. life expectancy compared Healthy life expectancy can also (Crimmins, Preston, and Cohen, to other high-income countries help to assess the extent to which 2011; Preston et al., 2014; Ng prevailing health conditions diverge (Alley, Lloyd, and Shardell, 2011; et al., 2014; Carter et al., 2015). - or converge with mortality pat Crimmins, Preston, and Cohen, Therefore, while smoking-related 2011). While weight increase in terns. The proportion of life lived mortality is declining for American the United States has been larger in good health, the ratio of HALE men and women, the history of and at earlier ages than other to life expectancy, is a measure of heavy smoking in the United States high-income countries, the obesity the compression or expansion of is still contributing to current and morbidity, or the extent to which epidemic is neither restricted to future life expectancy estimates the United States nor to younger the extra years of life lived are in and projections and to the poor - people (Ng et al., 2014). The preva a state of good or poor health and international ranking of U.S. life well-being. For example, among lence of adult obesity ranges from expectancy at age 50 (Preston, Glei, over 60 percent in some Pacific European countries, Slovakia had and Wilmoth, 2011). Meanwhile, - the lowest proportion of remain - Island nations to less than 2 per the time lapse for smoking decline cent in Bangladesh (Stevens et al., ing years of life expectancy at age in other high-income countries 2012; Ezzati and Riboli, 2013; Ng 65 in good health—16 percent for (for example in Western Europe) et al., 2015). At ages 50 and older, women and 23 percent for men. means that the mortality impact the United States has the highest Sweden, on the other hand, had will continue to play out for many the highest proportion at age 65 level of obesity when compared to years with uncertainty about the other high-income countries. Only of remaining years with no activity exact trajectory; more fine-grained limitation—73 percent for women older English men and Spanish data about smoking intensity and and 77 percent for men. women approach the levels of obe - duration are required for more sity found among older U.S. men precise projections (Michaud et al., BIG IMPACTS, OPPOSITE and women (Crimmins, Garcia, and 2011; Ng et al., 2014; Bilano et al., DIRECTIONS? SMOKING AND Kim, 2011). 2015). The majority of smokers OBESITY worldwide live in low- and middle- Clustering of risk factors increases Risk factors, such as tobacco use, income countries (Ezzati and Riboli, as age advances and increases the physical inactivity, obesity, mid- - 2013), where, for example, smok risk of disease and poor health life hypertension, and household ers exceed 70 percent of men aged (Negin et al., 2011a; Teo et al., An Aging World: 2015 U.S. Census Bureau 38

49 included over 38,000 respondents - of individual risk factors and risk 2013). For example, the combina aged 50 and older found a high factor clusters are rapidly changing tion of dietary risk factors and - proportion of individuals with mul physical inactivity was responsible by age, sex, education, and wealth at the individual level, as well as for 10 percent of global disability- tiple risk factors (Wu et al., 2015). adjusted life years (DALYs) in 2010 within and between high-, middle-, China, Ghana, and India had com - 2 paratively lower rates of multiple A multicountry (Lim et al., 2012). and low-income countries (Dans study of NCD risk factors that et al., 2011; Hosseinpoor et al., risk factors than Mexico, Russia, and South Africa (Figure 4-5). 2012; Lim et al., 2012). Ongoing 2 Another cross-Asian study found surveillance and interventions will One DALY can be thought of as 1 lost year of “healthy” life. The sum of these DALYs that over 70 percent of adults aged be required to prevent NCDs and across the population, or the burden of dis - to model the current and future 25 to 64 had three or more risk ease, can be thought of as a measurement of the gap between current health status and an factors for chronic NCDs (Ahmed et impacts of risk factors on health - ideal health situation where the entire popula (Ng et al., 2006; Bonita, 2009). al., 2009). The nature and patterns tion lives to an advanced age, free of disease and disability. Figure 4-5. Percentage Distribution of Cumulative Risk Factors Among People Aged 50 and Over for Six Countries: 2007–2010 5 risk factors 6 risk factors None 1 risk factor 2 risk factors 4 risk factors 3 risk factors China Ghana India Mexico Russia South Africa 30 10 20 50 40 0 60 70 80 90 100 Percent Note: Risk factors include current daily tobacco use, frequent heavy drinking, hypertension, insufficient vegetable and fruit intake, low level of physical activity, and obesity. Source: Wu et al., 2015. Adapted from Figure 2. An Aging World: 2015 39 U.S. Census Bureau

50 to 2000s (Ezzati et al., 2008; With U.S. life expectancy at birth hypertension. In fact, a measure and at age 65 falling behind many Danaei et al., 2010). Generally, that captures functioning and pres - ence of health conditions together men and women living in the other high- and middle-income resulted in no differences in (poorer) southern states of the countries, the American wealth- United States had lower healthy life health when comparing the United health paradox (wealthiest larger States and England (Banks et al., country, but not the healthiest in expectancy than elsewhere in the country (Figure 4-6), and regional the world) and increasing regional 2006; Cieza et al., 2015). A better variability in the United States inequalities in mortality appear understanding of the key dynam - ics contributing to the U.S. health to be growing (Wilmoth, Boe, and - confounds current understand ing about population health and disadvantage relative to other high- Barbieri, 2011; Olshansky et al., well-being (Murray et al., 2006; 2012). Yet, the results are not all in - income countries, and a standard a negative direction for the United Woolf and Aron, 2013). Smoking, ized metric for measurement, may States: it has higher survival after obesity, and high blood pressure well inform trajectories of aging contributed to the relative increase age 75 than many high-income and health in many other contexts. countries, lower current smoking in female mortality as compared to male mortality from the 1980s rates, and better management of Figure 4-6. United States Healthy Life Expectancy at Age 65 by Sex and State: 2007–2009 (In years) Men Women Years 15.0 or more 14.3 to 14.9 13.1 to 14.2 DC DC Fewer than 13.1 State average Male: 12.9 Female: 14.8 Source: Centers for Disease Control and Prevention, 2013. Adapted from Figure 1. An Aging World: 2015 U.S. Census Bureau 40

51 Box 4-1. Early Life Conditions and Older Adult Health By Mary C. McEniry, University of Wisconsin-Madison Adult health, disease, and mortality in later life are influenced by early life factors (Barker, 1998; Crimmins and Finch, 2006; Smith et al., 1998). Research also supports the influence of the social determinants of health and socioeconomic conditions on health outcomes later in life (Marmot and Wilkinson, 2005; Almond and Currie, 2010). These findings demonstrate the importance of a life-course approach to understanding older adult health. This life-course approach has expanded our understanding of modern shifts in life expec - tancy in diverse settings. The intriguing links between early life adversities and later life health can be examined through the rapid mortality declines during the 1930s to the 1960s in less developed countries (Palloni, Pinto-Aguirre, and Pelaez, 2002). During this period, less developed countries experienced significant reductions in infant and child mortality triggered by the medical and public health revolution (Preston, 1976). However, adults born during these 4 decades were still exposed to poor socioeconomic conditions, poor nutrition, and infectious diseases as infants and children. Exposure to these conditions in early life can increase the risk of poor health at older ages and, in particular, increase the risk of adult diabetes, obesity, and heart disease (Barker, 1998; Elo and Preston, 1992; Lillycrop et al., 2014; Tarry-Adkins and Ozanne, 2014). Cohorts increasingly characterized by their exposure to and survivorship of poor early life conditions may be - at higher risk of poor health at older ages, especially for diseases known to originate in early life. The pro jected large increases in adult health conditions, such as diabetes, obesity, and heart disease, may well have their origins in the past (Murray and López, 1996; Hossain, Kawar, and El Nahas, 2007). These circumstances may also have important implications for older adult health for at least the next 20 to 30 years (Palloni, Pinto-Aguirre, and Pelaez, 2002). The timing of rapid mortality decline was different across countries for the birth cohorts of the 1930s to 1960s. The present-day middle-income countries, such as Costa Rica, experienced rapid mortality reductions in the 1930s and 1940s, whereas several of today’s low-income countries did not experience significant mor - tality changes until the 1950s and 1960s. If early life events indeed have large impacts on adult health, and if differences in timing and pace of mortality decline created cohorts with markedly different health patterns in later life, then differences in health patterns for adults aged 60 and over should appear. A newly compiled data set contains harmonized cross-sectional and longitudinal data from major surveys of older adults or households in 20 countries and areas in Asia, Africa, and Latin America, as well as England, the Netherlands, and the United States (McEniry, 2013). The countries contributing data are diverse in their patterns of mortality decline and early life nutrition and infectious disease environments during the 1930s to the 1960s. The data set includes both very poor and wealthier countries and areas in the 1930s, including those that saw their economic status rise over time (e.g., Barbados, Puerto Rico, and Taiwan) and their aver - age caloric intake increase (China, Costa Rica, Mexico, and others) (Table 4-4). These data reveal health patterns in older adults born during periods of rapid demographic changes, par - ticularly for adult diabetes in the cohort born in the 1930s and 1940s. Figure 4-7 compares country-specific prevalence of self-reported diabetes for these older adults surveyed in the 2000s with country-level per- capita daily caloric intake in the 1930s and 1940s during their childhood. A high prevalence of adult diabetes is found for those born in very poor caloric intake countries that experienced significant and rapid mortality decline in the 1940s (countries labeled C and D in Figure 4-7). The prevalence is higher than for those born in Continued on next page. An Aging World: 2015 41 U.S. Census Bureau

52 countries that experienced a more gradual mortality decline (countries labeled A and B), or countries that did not experience significant mortality decline (countries labeled E). Being born into a country that experienced rapidly increasing life expectancy during the 1940s (labeled C and D) increased the odds of adult diabetes by 61 percent to 72 percent and of adult obesity by 46 percent to 53 percent (McEniry, 2014). Even though the numbers in the graph for diabetes are self-reported and are probably underestimated, especially for low- and middle-income countries, the prevalence of diabetes in C and D countries is higher now than what appeared historically in more developed countries (labeled A) (Wilkerson and Krall, 1947; Gordon, 1964; García-Palmieri et al., 1970; Hadden and Harris, 1987; Harris et al., 1998). With more accurate information about the preva - lence of diabetes, the steepness of the line would most likely increase, suggesting a larger contrast between middle- and high-income countries. The rapid demographic changes between the 1930s and the 1960s may help explain these health patterns and predict what is to come for adults in low-income countries born in the 1950s and 1960s. Two avenues of research hold promise in further examining early life conditions and older adult health. The epigenetic basis for disease may lead to developing future therapeutic approaches to prevent or address dis - ease. Epigenetic patterns may also provide clearer evidence about lifetime health risks resulting from expo - in utero and in childhood (Horvath, 2013; Lillycrop et al., 2014). On the other hand, emerg - sures that occur ing interest in using genomic data with social science survey data may provide a better understanding of how genes and early life environment combine to influence adult health. Recent evidence shows that poor early life conditions can impact gene expression at older ages (Levine et al., 2015). Both research avenues have the potential to lead to informed health policy that benefits those exposed to poor early life conditions. Table 4-4. GDP per Capita and Caloric Intake in Selected Countries and Areas: 1930s and 2000s Caloric intake GDP per capita Income group Country 2000s 1930s 1930s 2000s Barbados ... High N 3,025 1,815 England 5,441 High 3,005 3,370 ... Netherlands ... 5,603 High 2,958 3,215 Puerto Rico 815 High 2,219 N ... N ... 1,150 High 2,153 Taiwan 3,732 United States ... 6,231 High 3,249 ... Upper middle 3,272 Argentina 3,275 4,080 Brazil Upper middle 2,552 2,885 1,048 ... ... 2,859 Upper middle 2,481 2,806 Chile Costa Rica ... 1,626 Upper middle 2,014 2,804 Cuba ... 1,505 Upper middle 2,918 3,051 3,172 Mexico ... 1,618 Upper middle 1,909 2,300 2,886 South Africa ... 2,247 Upper middle Uruguay 4,301 Upper middle 2,902 2,831 ... Bangladesh ... 659 Low 2,021 2,125 568 China ... 2,201 Lower middle 2,908 Ghana 878 Low 2,311 2,596 ... 2,314 ... 726 Lower middle 2,021 India 2,498 2,040 Indonesia ... 1,141 Lower middle N Not available. Note: GDP per capita is expressed in 1990 international dollars. Income group reflects World Bank categories. Puerto Rico was classified as high income due to its relationship with the United States. Caloric intake is daily caloric intake per capita. Source: McEniry, 2014. Adapted from Table 1.1 and Table 2.1. Continued on next page. An Aging World: 2015 U.S. Census Bureau 42

53 Figure 4-7. Caloric Intake in Early Life and Diabetes in Later LIfe Age-standardized diabetes prevalence (percent) 30 C. Puerto Rico 25 C. Costa Rica D. Mexico 20 D. Mexico-SAGE D. Brazil D. Mexico-MHAS C. Taiwan A. US-HRS E. Bangladesh 15 B. Uruguay B. Cuba C. Chile C. South Africa A. US-WLS B. Argentina D. Russia 10 A. UK A. Netherlands E. China-SAGE E. China-CLHLS E. India 5 E. China-CHNS E. Indonesia 0 3400 3200 1800 2800 2600 2400 2200 2000 3000 Calories Notes: A = more developed countries, experiencing earlier and gradual mortality decline (beginning or prior to mid 20th century) B = less developed countries, experiencing earlier and more gradual mortality decline (early to mid 20th century) C = less developed countries, experiencing later and more rapid mortality decline (around 1930s) D = less developed countries, experiencing later and more rapid mortality decline (around 1940s) E = less developed countries, experiencing very late rapid mortality decline (after 1950s) CLHLS = Chinese Longitudinal Healthy Longevity Survey CHNS = China Health and Nutrition Study HRS = Health and Retirement Study MHAS = Mexican Health and Aging Study SAGE = Study on Global Ageing and Adult Health WLS = Wisconsin Longitudinal Study For a complete listing of surveys used in the figure, see McEniry, 2014. Source: McEniry, 2014. Adapted from Figure 4.2. An Aging World: 2015 43 U.S. Census Bureau

54 CHANGE IS POSSIBLE! Figure 4-8. The good news is that large-scale Projected 2025 Deaths by Age, Income Level, and - chronic disease prevention is possi Projection Assumptions - ble, resulting in gains in both popu Aged 30 to 69 Aged 70+ lation health and wealth (Bloom et High-income countries al., 2011; Capewell and O’Flaherty, 2011; Ezzati and Riboli, 2012; Number of deaths in 2010 Franco et al., 2013). Modification or elimination of health risk factors, At 2010 death rate even for men and women aged 75 and older, can add years to life (Rizzuto et al., 2012). The benefits Business-as-usual trend of risk factor modification are most clear for control of hypertension Achieving targets for risk factors and high cholesterol in older adults (Prince et al., 2014). High-income Achieving more - countries are doing better at treat ambitious tobacco use target ment for these chronic diseases 0 30 10 40 20 than middle-income countries Millions (Crimmins, Garcia, and Kim, 2011; Low- and middle-income countries Lloyd-Sherlock et al., 2014). Number of deaths in 2010 While significant health gains can be realized from changes in risks at older ages, changes earlier in life At 2010 death rate will compound the benefits (Sabia et al., 2012; Danaei et al., 2013; Wong Business-as-usual trend et al., 2015). Current projections for reduction of the major risk factors, Achieving targets for risk factors including smoking and obesity, show the potential benefit of the Achieving more resulting decrease in deaths (see ambitious tobacco use target Figure 4-8) from four main NCDs 40 0 10 20 30 (cardiovascular diseases, chronic Millions respiratory diseases, cancers, and Note: Number of deaths due to cardiovascular diseases, chronic diseases, cancers, and diabetes. diabetes) and is likely an underesti - Source: Kontis et al., 2014. Adapted from Figure 4B. mate of the full impact (Kontis et al., 2014; Carter et al., 2015). An Aging World: 2015 U.S. Census Bureau 44

55 2008). The per-capita disease bur 2011)? Other researchers (Fries, - WHAT DOESN’T KILL YOU, 1980; Gruenberg, 1977; Manton, den, DALYs/1000 population, for MAKES YOU . . . POSSIBLY older adults is higher in low- and 1982) recommend using a metric of UNWELL middle-income countries than in decrements in functioning to define For most countries, age- and sex- high-income countries (Prince et population health and aging. Still specific mortality is decreasing, with al., 2014). other researchers recommend that a progressive shift towards a larger a combination of both number of share of deaths caused by NCDs The largest increases from 1990 to chronic diseases and decrements and injury (GBD 2013 Mortality 2010 are seen in the burdens from in functioning be used (Cieza et al., and Causes of Death Collaborators, dementia (113 percent) and diabe - 2015; Beltrán-Sánchez, Razak, and 2015). This means that more people tes (79 percent; Table 4-5). The five Subramanian, 2014). are living longer with these chronic most burdensome conditions for conditions and the resulting decre - adults aged 60 years and older in The global burden of NCDs, such ments in health. The loss of health, 2010 are ischaemic heart disease - as heart and lung diseases, diabe - not including death, is more diffi tes, depression, and dementia, in (77.7 million DALYs), stroke (66.4 cult to quantify. Does the presence people aged 60 and older grew by million DALYs), chronic obstructive of chronic disease in one of two 33 percent between 1990 and 2010 pulmonary disease (43.3 million otherwise identical populations (Prince et al., 2014). People in this DALYs), and diabetes (22.6 million make the population without the broad older age group account for DALYs; Table 4-5). disease healthier (Banks et al., 2006; 23.1 percent of the total disease Martinson, Teitler, and Reichman, burden (World Health Organization, Table 4-5. Disability-Adjusted Life Years (DALYs) Attributable to Chronic Noncommunicable Diseases for World Population Aged 60 and Over: 1990 and 2010 (Nmbers in millions) 2010 1990 Change 1990– Chronic noncommunicable disease 2010 Percent Number Percent of total Number Percent of total ... 54.5 12.5 66.4 11.6 21.8 Cerebrovascular disease –3.1 Chronic obstructive pulmonary disease . . . 44.7 10.3 7.5 43.3 ... Dementia 1.1 10.0 1.7 112.8 4.7 Diabetes mellitus 12.6 2.9 22.6 3.9 79.4 ... Hearing impairment ... 5.3 1.2 7.5 1.3 41.5 Ischaemic heart disease ... 60.7 14.0 77.7 13.5 28.0 ... 1.6 10.4 7.0 Vision impairment 48.6 1.8 Note: One DALY can be thought of as one lost year of “healthy” life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. Source: Prince et al., 2014. Adapted from Table 1. An Aging World: 2015 45 U.S. Census Bureau

56 Box 4-2. The Rising Tide of Aging With HIV By Joel Negin and Robert Cumming, University of Sydney The HIV pandemic has had a profound impact across the world. In 2013, an estimated 35 million people were living with HIV and the global response to the epidemic has been unprecedented in terms of funding, attention, and action (Joint United Nations Programme on HIV/AIDS, 2014). Despite considerable progress, important gaps remain in the global HIV response. Older adults have long been neglected despite important evidence of the growing impact among those aged 50 and older in both developing and developed countries (Mills, Barnighausen, and Negin, 2012). As of 2013, more than one-third of those living with HIV in North America and Western Europe were aged 50 and older (Mahy et al., 2014; Joint United Nations Programme on HIV/AIDS, 2014). In Latin America, 15.4 percent of those living with HIV were in this age group and in Sub-Saharan Africa—the region most affected by HIV—almost 12 percent were aged 50 and over (Joint United Nations Programme on HIV/AIDS, 2014). The numbers are increasing, with a dramatic rise in those aged 50 and older living with HIV in all regions of the world (Figure 4-9). In Sub-Saharan Africa, there are already more than 2.5 million adults aged 50 and over living with HIV. This rapid increase in the HIV burden among older adults can be attributed to a number of factors. Principally, the 13 million people accessing anti-retroviral treatment are living longer with life expectancies returning to near normal in most countries (Joint United Nations Programme on HIV/AIDS, 2014; Mills et al., 2011). Therefore, many individuals are now aging with HIV into their 50s and beyond. In addition, older adults remain sexually active and condom use among those aged 50 and over remains low, thus putting these individuals at risk of HIV transmission (Drew and Sherrard, 2008; Freeman and Anglewicz, 2012). In general, older adults have lower levels of HIV-related knowledge than younger adults (Figure 4-10). Lack of knowledge works to impede preventative actions and, as a result, contributes to emerging evidence of new HIV infection among older adults (Wallrauch, Barnighausen, and Newell, 2010). Lower levels of HIV-related knowledge and HIV testing among older adults not only have implications for HIV transmission, but for HIV treatment as well. Those aged 50 and older have smaller CD4+ T-cell gains while on treatment (Vinikoor et al., 2014). They also have poorer therapy outcomes than younger adults (Bakanda et al., 2011; Negin et al., 2011b). The emergence of multimorbidity is a further challenge for HIV care as a result of living longer with HIV. Aging with HIV means older individuals often have the additional burden of multiple chronic health conditions. Older people living with HIV have high rates of kidney disease, cognitive impairment, and metabolic abnormalities (Calvo and Martinez, 2014; Cysique and Brew, 2014; Nadkarni, Konstantinidis, and Wyatt, 2014). There is ongoing debate whether claims of accelerated aging as a result of HIV and its treatment have been overstated (Justice and Falutz, 2014). However, there is evidence from South Africa that those living with HIV have mark- ers of accelerated aging—reduced telomere length and CD2NKA expression—when compared to HIV-negative individuals (Pathai et al., 2013). Prevention, testing, and treatment services targeted at older adults and designed appropriately will help ensure an inclusive response to the continuing HIV epidemic. Continued on next page. An Aging World: 2015 eau U.S. Census Bur 46

57 Figure 4-9. Number of People Aged 50 and Over Living With HIV for Selected Regions: 1995 to 2013 Thousands 3000 Sub-Saharan Africa 2500 2000 1500 1000 Western and Central Europe and Northern America 500 Asia and the Pacific Latin America 0 2001 1995 2010 2007 2004 2013 1998 Note: Regional grouping per UNAIDS, 2014. Source: Joint United Nations Programme on HIV/AIDS (UNAIDS), 2014. Figure 4-10. Percentage With Comprehensive Knowledge About HIV and AIDS by Age and Country: Selected Years 50–59 15–49 51.6 43.0 42.7 39.7 31.3 31.0 29.2 26.5 24.5 23.3 Ethiopia 2011 Lesotho 2009 Rwanda 2010 Sierra Leone 2013 Uganda 2011 Sources: ICF International, 2014; Demographic and Health Surveys, various countries and years. 47 An Aging World: 2015 U.S. Census Bureau

58 of antiretroviral therapy (Negin et low income, low level of educa - PRESENCE OF MULTIPLE tion, and unemployment (Boutayeb, al., 2012; Deeks, Lewin, and Havlir, CONCURRENT CONDITIONS Boutayeb, and Boutayeb, 2013). One 2013), multimorbidity is an even INCREASES WITH AGE bigger problem. In one study, 91 study of 28 countries (Afshar et al., NCDs often occur together and 2015), using highest level of educa - percent of older adults with HIV had when two or more such chronic tion as a proxy for socioeconomic one comorbidity condition and 77 health conditions occur, it is termed percent had multiple comorbidity status, reveals a positive association “multimorbidity” (Boyd et al., 2008; conditions (Karpiak, Shippy, and between age and multimorbidity Fortin et al., 2010; Diederichs, Cantor, 2006). The most common and a negative association between Berger, and Bartels, 2011). The comorbidities in that study were education and multimorbidity complex care required to manage across different regions (Table 4-6). depression (52 percent), arthritis multimorbidity often adversely (31 percent), hepatitis (31 percent), Compared with the reference group impacts health and quality of life - (odds ratio of 1.00), an odds ratio neuropathy (30 percent), and hyper and increases health service use greater than “1” indicates that the tension (27 percent). A challenge (Schoenberg et al., 2007; Lehnert for aging with HIV is the additional comparison group was more likely et al., 2011; Barnett et al., 2012). to have multimorbidity; and an odds layer of treatment-related complex - Evidence from both high- and low- ratio smaller than “1” indicates the ity and associated adverse effects income countries indicates that (High et al., 2012). opposite. The results here point older age is a risk for multimorbid - to a higher multimorbidity burden ity, from over 30 percent in India TREND OF AGE-RELATED in those who are older or the least and 58 percent in Bangladesh, to 60 DISABILITY VARIES BY educated in both higher- and lower- percent in Spain and Germany, and COUNTRY income countries. In a study of six 76 percent among Scottish adults countries, multimorbidity showed Whether the additional years of life aged 75 and older (Khanam et al., clear age, sex, and wealth patterns, lived will be in good or poor health 2011; Kirchberger et al., 2012; Pati with resulting higher levels of dis - remains contested, but research et al., 2014; McLean et al., 2014; ability, depression, and poor quality suggests that the aging process Garin et al., 2014). of life (Arokiasamy et al., 2015). is modifiable (Christensen et al., A review of 26 studies from WHO’s 2009). Data show that disability For the growing population of Eastern-Mediterranean countries rates rise with age (He and Larsen, older adults with HIV (Negin and reported that a higher prevalence - 2014; Table 4-7). An examina Cumming, 2010), now considered a of multimorbidity is associated with tion of limitation in activities of chronic condition given the success Table 4-6. Odds Ratios for Effect of Age, Sex, and Educational Attainment on Multimorbidity for World Regions: 2002–2004 Age Sex Educational attainment Region Less than 55 and Male Female Under 55 primary Primary Secondary Higher over 1.00 All regions 0.97 0.97 1.00 ***1.33 ***0.59 ***4.10 1.00 ... Africa 0.99 1.00 ***1.64 1.00 0.90 ***0.56 ***3.13 1.00 ... ... 1.00 ***2.99 ***0.43 1.00 ***1.31 1.00 0.91 0.81 Central and South America Eastern Europe and Central Asia ***6.02 ***0.49 ***0.60 1.00 1.17 1.00 ***0.59 1.00 ... ***0.53 South Asia ... 1.00 ***4.08 ***0.68 1.00 ***1.36 ***0.46 1.00 1.00 ***1.81 1.00 **0.82 0.90 South East Asia ... 1.00 ***3.09 ***0.80 ... 1.00 ***1.61 1.00 ***0.53 ***5.95 1.00 ***0.40 Western Europe ***0.18 Notes: * p-value<0.05; ** <0.01; *** <0.001. Regional grouping per Afshar et al., 2015. Source: Afshar et al., 2015. Adapted from Table 4. Table 4-7. Disability Prevalence Rate by Age Group for Malawi: 2008 (In percent) Total Male Female Age group 4.4 5 and over ... 4.3 4.3 2.9 5 to 14 ... 2.8 2.6 4.2 4.2 ... 15 to 64 4.2 65 and over ... 17.6 17.1 18.0 Source: Malawi National Statistical Office, 2010. An Aging World: 2015 U.S. Census Bureau 48

59 daily living (ADLs) in 12 European countries, Israel, and the United Figure 4-11. States shows a steady rise with Activity of Daily Living Limitations by Age for age in all countries. The increase the United States and England: 1998 to 2008 is considerable between the ages Mean ADL 0.9 of 50 and 70 in Greece, Italy, and United States Spain, whereas increases are more evident in adults aged 70 and older 0.8 in the Netherlands, Sweden, and Switzerland (Chatterji et al., 2015). Levels of ADL limitations have been falling steadily across consecutive 0.7 study cohorts in England compared to the United States (Figure 4-11). In the United States, the mean 0.6 proportions of ADL have steadily 1998 increased across all ages older than 2002 - 50, while in England, the propor 2004 0.5 tions decreased except for those at 2006 the oldest ages (Figure 4-11). 2008 FRAILTY IS A PREDISABLED 0.4 STATE - Frailty and disability are interre lated yet have distinct conditions. 0.3 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 50 The classifications and definitions Age of frailty are numerous, with no Mean ADL consensus at this point (Abellan 0.9 van Kan et al., 2008). However, two England definitions are often operational - ized as a physical phenotype (Fried 0.8 et al., 2001) and a multidomain phenotype (Rockwood, 2005). One - description of frailty is a multi 0.7 dimensional syndrome of loss of reserves (energy, physical ability, cognition, or health) that gives rise to vulnerability (Rockwood et al., 0.6 2005). In this case, frailty could be a predisabled state. An individual could be frail but without any 0.5 2002 disabilities; or frail people could 2004 have comorbidity and disability. 2006 A study comparing community- 2008 0.4 dwelling adults aged 50 and older found clear socioeconomic gradi - - and lower-income ents in higher countries—individuals with lower 0.3 60 68 62 64 66 50 52 54 56 58 70 72 74 76 78 80 education and wealth levels were Age more likely to be frail. The study Note: U.S. data are from the Health and Retirement Study; English data are from the also reported higher levels of frailty English Longitudinal Study of Ageing. in older age and higher rates in Source: Chatterji et al., 2015. Adapted from Figure 1. women than men (Harttgen et al., 2013). An Aging World: 2015 49 U.S. Census Bureau

60 meaning and purpose of one’s life. Although in high-income countries THE U-SHAPE OF Finally, hedonic well-being refers to subjective well-being has a typi - SUBJECTIVE WELL-BEING cal U-shaped pattern with age, it everyday feelings or moods, such BY AGE IS NOT OBSERVED EVERYWHERE progressively decreases in older as experienced happiness, sadness, anger, and stress. adults in the former Soviet Union, Quality of life is important at all Eastern Europe, and Latin America. ages, but in later life it becomes - Looking at aspects of life evalu This pattern is corroborated by of paramount importance for the ation and hedonic well-being, a evidence from Finland, Poland, and remaining years to be lived. As life U-shaped pattern is more evident Spain, where poor health status is - expectancy increases and treat in high-income, English-speaking significantly associated with nega - ments for life-threatening disease countries (Figure 4-12), compared tive emotional status and reduced become more effective, the issue of to other regions where life satisfac - life satisfaction (Miret et al., 2014). maintaining well-being at advanced tion either declines at older ages, The dynamics between good health ages is growing in importance or remains rather stable across the and subjective well-being are (National Research Council, 2013). lifespan (Sub-Saharan Africa). Lack associated with longer survival, Yet research into subjective well- of happiness (as an experienced which increases support for these being and health at older ages is moment-to-moment emotion) is to be goals of economic and social at an early stage (Steptoe, Deaton, rather uncommon in high-income policies (Stiglitz, Sen, and Fitoussi, and Stone, 2014). Within subjective English-speaking and Latin America 2010). To achieve the proposed well-being, at least three different and Caribbean countries, but quite post-2015 development agenda - approaches have been used to cap common in transition countries goal of promoting well-being at ture different aspects of well-being. (countries of the former Soviet all ages will require a focus on One approach is life evaluation that - Union and Eastern Europe), includ the health of the older population generally refers to one’s overall ing nearly 70 percent of those aged (Suzman et al., 2014). life satisfaction or general happi - 65 and older who were not happy ness with one’s life. Eudemonic on the previous day (Steptoe, well-being, a second approach, Deaton, and Stone, 2014). focuses on judgments about the An Aging World: 2015 U.S. Census Bureau 50

61 Figure 4-12. Male Well-Being and Happiness by Age and Sex in Four Regions: 2006–2010 Female Life evaluation Unhappiness High-income English-speaking countries High-income English-speaking countries Mean score Proportion 0.6 8 7 0.4 6 0.2 5 4 0.0 35–44 45–54 25–34 15–24 55–64 65–75 45–54 55–64 65–75 15–24 25–34 35–44 Age Age Countries of the former Soviet Union and Eastern Europe Countries of the former Soviet Union and Eastern Europe Mean score Proportion 8 0.6 7 0.4 6 0.2 5 4 0.0 55–64 65–75 15–24 35–44 45–54 25–34 45–54 35–44 25–34 15–24 65–75 55–64 Age Age Sub-Saharan Africa Sub-Saharan Africa Mean score Proportion 8 0.6 7 0.4 6 0.2 5 4 0.0 65–75 15–24 25–34 35–44 45–54 55–64 55–64 35–44 45–54 65–75 15–24 25–34 Age Age Latin America and the Caribbean Latin America and the Caribbean Mean score Proportion 8 0.6 7 0.4 6 0.2 5 4 0.0 25–34 35–44 45–54 55–64 65–75 15–24 15–24 35–44 45–54 55–64 65–75 25–34 Age Age Note: Cantril ladder ranges from 0 (worst possible life) to 10 (best possible life). Source: Steptoe, Deaton, and Stone, 2014. Adapted from Figure 1 and Figure 5. An Aging World: 2015 51 U.S. Census Bureau

62 Box 4-3. Epigenetics of Aging By Kirstin N. Sterner, University of Oregon Most health outcomes associated with aging result from a complex interplay of an individual’s genome and life experiences. Life experiences and environmental factors influence the expression of complex genetic traits, making it difficult to identify specific genetic markers that can be used to slow aging or unambigu - ously diagnose, treat, or prevent aging-related diseases. The epigenome helps mediate these gene-environ - ment interactions and, therefore, has the potential to provide insights into aging and disease processes. Life experiences, such as stress, nutrition, and environmental exposure, can affect the genome through “epi - genetic modifications,” which are biochemical alterations of the genome and chromatin that make specific regions of the genome more or less accessible to the cell’s transcriptional machinery without changing the underlying DNA sequence itself. The results of these biochemical modifications are changes in gene expres - sion (when genes are turned on/off and the quantity of gene product made). Unlike the genome, the epig - enome can be dynamic and flexible, and varies across tissue/cell types and the lifespan. - One of the most commonly studied forms of epigenetic modification is DNA methylation. In DNA methyla tion, a methyl group is added to a cytosine in the genome sequence by DNA methyltransferases. A modified cytosine is typically followed by a guanine, forming a “CpG” site. DNA methylation typically reduces gene expression. During the normal aging process, there is an overall reduction in DNA methylation across the genome, although increases have been observed in more localized regions (D’Aquila et al., 2013). This raises the question of whether DNA methylation status can be used as a biomarker of aging and aging-related diseases. - A number of recent studies have identified epigenetic markers associated with common aging-related dis eases, including Alzheimer’s, cardiovascular disease, and cancers, although the significance of these findings is unclear (Kanherkar, Bhatiq-Dey, and Csoka, 2014; Jung and Pfeifer, 2015). In addition, some epigenetically modified CpG sites predict age in specific tissues and across tissue and cell types (Hannum et al., 2013; Horvath, 2013). These sites behave in a clocklike manner, with a higher rate of methylation early in life that slows after adulthood and can be used to estimate an individual’s methylation age (Horvath et al., 2014). In most cases, methylation age and true chronological age are highly correlated. When methylation age and chronological age differ, it may suggest acceleration or deceleration of aging (see note). There is a growing interest in identifying lifestyle, environmental, and genetic factors that are associated with age acceleration to better understand aging-related diseases. While use of epigenetic data and the epigen - etic clock is relatively new to aging-research, a number of recent studies hint at its potential. For instance, methylation age acceleration is associated with decreased lung function, grip strength, and cognition and increased all-cause mortality (Marioni et al., 2015a; Marioni et al., 2015b). Horvath (2013) used the epigen - etic clock to identify evidence of age acceleration in liver tissue, adipose tissue, muscle, and blood. A study of German patients found a strong correlation between body mass index (BMI) and liver disease, and between BMI and age acceleration (Horvath et al., 2014; Figure 4-13). Age acceleration was defined as the residual resulting from the regression of methylation age on chronological age. Further research is needed to deter - mine: 1) the molecular mechanisms that underlie age acceleration; 2) how divergent patterns of methylation influence health outcomes associated with aging; and, 3) how the epigenome changes throughout an indi - vidual’s lifetime. Continued on next page. An Aging World: 2015 U.S. Census Bureau 52

63 Figure 4-13. Age Acceleration in Liver Tissue and BMI Female Male Years 10 5 0 –5 –10 –15 80 10 70 60 20 30 40 50 BMI Note: Age acceleration is when someone’s epigenetic age, as measured overall or in particular body parts like the liver, is deemed to be older than chronological age. BMI is body mass index. The dashed line indicates the regression line and data point corresponds to a human subject. Age acceleration in liver tissue is significantly correlated with BMI (r=0.42, P=6.8X10-4). Source: Horvath et al., 2014. Adapted from Figure 1E. 53 An Aging World: 2015 U.S. Census Bureau

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75 CHAPTER 5. Health Care Systems and Population Aging Increasing longevity will force based on potential recipients, INCREASING FOCUS ON adjustments to health care systems range and quality of services to be UNIVERSAL HEALTH CARE and finance, retirement policies provided, and financing of those AND AGING and pensions, and likely labor and services (Stuckler et al., 2010; As part of the post-Millennium capital markets (Lutz, Sanderson, Global Health Workforce Alliance Development Goals set by the and Scherbov, 2008; Bloom, and World Health Organization, United Nations (UN), universal Canning, and Fink, 2010; Lee and 2013; Global Health Watch, 2014). health coverage has become a Mason, 2011; National Research In some countries, UHC is viewed focus for the post-2015 Sustainable Council, 2012). Population aging is as a health insurance model that Development Goals (United frequently placed in the framework would provide a means-tested, Nations, 2012). Multiple interna- of whether health services, welfare basic package of limited services tional organizations and many provision, and economic growth with a multitude of service buyers governments argue that health and are sustainable, dismissing the and providers, while in other coun- other systems should be refor - substantial social, economic, and tries it is a single provider, public mulated to eliminate or minimize cultural contributions from older tax-financed system based on the inequalities and maximize healthy adults (Lloyd-Sherlock et al., 2012). principles of equality of access for life expectancy, capabilities, and all who need care. well-being in older ages (Sen, 1999; Aging is a concern for costs to Krueger et al., 2009; Stiglitz, Sen, health care systems, as much as Today close to half of the countries and Fitoussi, 2009; Marmot, 2013; health care costs are a concern for worldwide are engaged in health Chatterji et al., 2015). The goal is older people, especially in settings - reforms as a result of the resur for people at all ages to receive the where there is limited institutional, gence in interest in UHC, and a health services they need without human, and financial resource little more than a half of the world undue financial hardship. capacity to meet the basic needs population is covered for about half of older people and where social of the possible services they need The World Health Organization safety nets do not exist. High- (Boerma et al., 2014; Marzouk, (WHO) defines the goal for uni- income countries may differ from 2014). Two years after the UN versal health coverage (UHC) as low- and middle-income countries General Assembly Resolution on ensuring that all people obtain the in readiness or resources available global health and foreign policy health services they need without to provide health care for an aging calling for UHC among all of its risk of financial ruin or impoverish- population. Member States (United Nations, ment, and presents the concept of 2012), a coalition of more than UHC in three dimensions: (1) the The growing number and share of 500 organizations from more than health services that are needed, older people in all societies are also 100 countries marked December (2) the number of people that need posing an increasing burden to old 12, 2014, as the first-ever them, and (3) the costs to whoever age care. Institutional long-term Universal Health Coverage Day must pay (WHO, 2010; 2013). UHC care and informal care combined (Universalhealthcoverageday.org, is understood and implemented in are some of the options to meet 2014; WHO and World Bank, 2015). many ways, with differences largely this challenge. 65 An Aging World: 2015 U.S. Census Bureau

76 However, significant differences or maintaining the health of older dividend—thriving lives, costing remain between more developed people (Cutler, Landrum, and less, contributing more” (Early countries and less developed coun- Stewart, 2006; McKee et al., 2009). Action Task Force, 2014). Given tries in coverage level (Table 5-1), this, the implications of popula- In both more developed and less and the urban/rural divide in tion aging on systems are far from developed countries, chronic health coverage and access is bleak if governments make the nec- noncommunicable diseases are the consistent across the world essary and targeted changes in the main causes of mortality, mor - (Scheil-Adlung, 2015). Furthermore, face of population aging (Economist bidity, and disability in old age. challenges common to all health Intelligence Unit, 2009; Bloom et Yet, throughout the world, health - care systems extend beyond cover al., 2015). Nevertheless, aging will systems are mainly designed to age and include financing and demand action on health care for provide episodic acute care. In quality (Massoud, 2014; USAID the older population (Boerma particular, health services geared Health Finance and Governance et al., 2014). to the needs of older people would Project, 2015). need to be strengthened and bet- HEALTH SYSTEMS IN There is considerable evidence that ter integrated with other levels of RESPONSE TO AGING population aging does not contrib- care to provide the continuum of The contribution of health care sys- ute substantially to growing health chronic care required (Tinetti, Fried, tems to population health has long care costs (Geue et al., 2014; Bloom and Boyd, 2012). The primary been contested, and while some et al., 2015; Yu, Wang, and Wu, health care system is also the best believe that health care does not 2015). Public health and health care channel to provide support to the contribute significantly to health, systems that successfully reorient informal caregiver who provides evidence is now emerging that sys- toward the health and long-term long-term, home-based care to a tems which promote the adoption care needs of the older popula- dependent older person. of healthy lifestyles are improving tion may help produce a “triple Table 5-1. Country Distribution of Share of Population Without Legal Health Coverage by Region 1–49% without 50–74% without 75–100% without Total 0% without coverage coverage coverage coverage number of Region Number of countries Percent of Number of Number of Percent of Percent of Percent of Number of region region countries countries region countries region countries studied Africa 61.7 29 12.8 6 17.0 8 4 47 8.5 ... Asia 14.0 43 16 37.2 6 32.6 7 16.3 ... 14 Europe ... 19 47.5 20 50.0 0 0.0 1 2.5 40 Latin America and the Caribbean 35.5 6 ... 9 29.0 31 16.1 11 19.4 5 Northern America 0 0.0 ... 2 1 50.0 1 50.0 0 0.0 Oceania 100.0 0.0 0 0.0 0 ... 0 4 4 0.0 Notes: Legal health coverage is defined as percentage of population affiliated to or registered in a public or private health system or scheme. Number of countries includes only countries with available data for legal health coverage; data as of latest available year. Source: Scheil-Adlung, 2015. (Percentage distribution calculated based on the Statistical Annex.) An Aging World: 2015 U.S. Census Bureau 66

77 The demographic transition is shift- be provided at home, rather than in well-coordinated health and social ing population epidemiology from a facility—regardless, primary care policies, thereby slowing the rate primarily acute infectious disease providers with geriatric training or of age-related health decline and to primarily chronic infectious and a comprehensive geriatric assess- the subsequent amount of services noninfectious disease. This alone ment in all settings provide better required (Goldman et al., 2013). would suggest a need to reorient outcomes (Ellis et al., 2011; O’Neill, Previous research on utilization health systems to ensure services 2011). Health system reforms of health services at old age in meet population needs, where that incorporate people-centered individual countries has found that health and social services are health services that are sensitive use peaks at about 80 years of integrated, with continuity of care to the health needs at all ages over age, falling in those who are older across different services. Aging the life course, including geriatric (McGrail et al., 2000; Kardamanidis populations will have different assessments in older age, would be et al., 2007). These findings were health care needs, with more peo- an effective approach to integration confirmed in the Survey of Health, ple affected by dementia, stroke, of care services (WHO, 2015). Ageing, and Retirement in Europe cancer, fractured hips, osteoporo- Even before needing formal or (SHARE) which surveyed 20,000 sis, Parkinson’s disease, lower back informal care, increased primary or Europeans over age 50 across 11 pain, sleep problems, and urinary secondary prevention efforts could countries. The survey found that incontinence, for example. As have significant impacts on health the use of health services peaks at mentioned in Chapter 4, it is also in older age, such as tobacco cessa- ages 75 to 79, levels off at age 80, likely that the complexity of health tion, cognitive training, and immu- and falls among those older than problems will increase as popula- nization programs for vaccine- 85 years (Chawla, Betcherman, and tions age, with more multimorbid- preventable diseases stemming Banerji, 2007). The Study on global ity and risk factor clustering, result- from human papillomavirus, influ- AGEing and adult health (SAGE) ing in a plethora of treatments enza- and pneumococcal-related surveyed 35,000 people aged 50 that potentially interact with each infections (Esposito et al., 2014). and older across six middle- and other (Dubois, McKee, and Nolte, lower-income countries and found 2006; Boyd and Fortin, 2010). This Additionally, greater attention to that the 70–79 age group had the complexity makes coordination the unique needs of aging minority highest likelihood of using both of care across health and social populations by the health and social outpatient and inpatient services services and integration across systems may improve their healthy (Peltzer et al., 2014). different levels of care particularly life expectancy. All older adults important. Some of this care might would benefit from appropriate and 67 An Aging World: 2015 U.S. Census Bureau

78 Box 5-1. Global Aging and Minority Populations: Healthcare Access, Quality of Care, and Use of Services By Karen I. Fredriksen-Goldsen, University of Washington In addition to the common concerns about aging, older adults from minority and migrant groups face addi - tional worries about support and access to services as they age. Barriers and discrimination at many levels may impact access to needed services for themselves or loved ones, formal financial arrangements and secu - rity, and physical accommodation in older age. The impact of discrimination and ongoing disadvantage over a lifetime are borne out by recent numbers: lower life expectancies and higher disease burdens. Despite recent attention, the gaps in life expectancy and other indicators are not closing, for instance, in indigenous populations in Australia, Canada, and New Zealand, and for those with lower levels of educa - tion (Olshansky et al., 2012; Mitrou et al., 2014). The variations in health often reflect differences by group status such as race, ethnicity, immigration, socioeconomic status, sexual and gender identities, and physical and mental abilities (National Institutes of Health, 2013). This is likely compounded by additional language, linguistic, and cultural barriers (Warnes et al, 2004; Bramley et al., 2005; Sayegh and Knight, 2013). Among lesbian, gay, bisexual, and transgender (LGBT) older adults, experiences of discrimination and victimization are linked to poor health outcomes, yet they often experience barriers to accessing care and remain largely invisible in services given their stigmatized identities (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen et al., 2013). Among those with intellectual, emotional, and physical disabilities, adjustments in healthcare information are often needed to better match capacity (Emerson et al., 2011). Health inequities, resulting from economic, environmental, and social disadvantage, are costly. In the United States, where the 65-and-older population has nearly complete health care coverage by Medicare, it is estimated that among Blacks, Hispanics, and Asian Americans, nearly one-third of direct healthcare expen - ditures are excess costs as a result of health inequities (LaVeist, Gaskin, and Richard, 2009). Furthermore, when examining differences in health care quality in the United States, those living in poverty, compared to those with high incomes, received worse care for 47 percent of the quality measures; people aged 65 and older received worse care for 39 percent of the quality measures compared to adults aged 18 to 44 (Figure 5-1; Agency for Healthcare Research and Quality, 2012). There were also significant differences by race and ethnicity. Ensuring appropriate access to and use of care and quality care are critical factors in the promotion of health, especially for racial and ethnic minorities, indigenous and aboriginal people, immigrants, LGBT people, as well as those with intellectual, emotional, and physical disabilities. Across population groups, several factors have been linked to inequities in health, including the heightened risk of exposure to social determinants of poor health (such as poverty, unemployment, isolation, and dis - crimination) and other structural and organizational barriers, including lack of available services and institu - tional and societal biases in services as well as policies (Braveman, Egerter, and Williams, 2011). In addition, older adults from these population groups may be at elevated risk of adverse health behaviors as well as at risk of reduced health literacy. They may also be reluctant to utilize healthcare services, preventative screen - - ings, and other health promotion activities. Promoting health equity, embedded within a life course perspec tive, is critical for older adults across diverse population groups to have the capacity to reach their full health potential (Fredriksen-Goldsen et al., 2014). Continued on next page. An Aging World: 2015 U.S. Census Bureau 68

79 Figure 5-1. Proportion of Quality Measures for Which Members of Selected Groups Experienced Better, Same, or Worse Quality of Care Compared With Reference Group in the United States: 2011 Better (Population received better quality of care than reference group) Same (Population and reference groups received about the same quality of care) Worse (Population received worse quality of care than reference group) Percent 100 80 60 40 20 0 Poor Asian Hispanic AIAN Black (ref. NHW) (ref. White) (ref. White) (ref. White) (ref. High Income) AIAN American Indian or Alaska Native. NHW Non-Hispanic White. Note: “ref.” is reference groups. Source: Agency for Healthcare Research and Quality, 2012. barriers to access, through univer care for chronic diseases. Health - HEALTH SYSTEM’S sal coverage efforts, would benefit systems in high-income coun - RESPONSE TO AGING IN tries are at different stages of this all people including vulnerable HIGH-INCOME COUNTRIES populations in wealthier countries evolution, but most have cost and Older population in higher-income (Nolte and McKee, 2012). continuity of care issues related countries are typically further along to long-term treatment of chronic - the epidemiologic transition; how Just as national health and social conditions. In some cases, the sys - ever, many of the existing health systems are at different stages in tems themselves, to some extent, care systems were created at the - their service capacity, some coun shape population preferences early stages of the antibiotic era tries have older adult populations (Mair, Quinones, and Pasha, 2015). and still need to evolve to provide with declining disability, while Regardless of preferences though, well-coordinated and integrated other countries have increasing removal of financial and other An Aging World: 2015 69 U.S. Census Bureau

80 of well-functioning health systems; poor countries alike. Yet, evidence disability (Wahrendorf, Reinhardt, about the contribution of late life whereas high-income countries are and Siegrist, 2013). These systems costs to lifetime health care costs is will need to invest in patient- more likely to have accurate and somewhat mixed (Alemayehu and centered prevention, treatment, complete vital registration systems - and palliation in correct propor (United Nations Statistics Division, Warner, 2004; Martini et al., 2007; Suhrcke et al., 2008; Ogawa et al., 2014). Another important differ - tions and across an integrated ence is in the quality of care, often continuum, incorporate cutting- 2009; Payne et al., 2009; Center for Studies on Aging—Lebanon, 2010; edge knowledge of what improves quite low in many low-income Tchoe and Nam, 2010; Medici, countries, with few professionals health as a population ages—not necessarily expensive new technol - 2011; World Bank, 2011). trained to provide multidisciplinary ogy—and offer health prevention geriatric care. Further complicating While health care costs at the matters is the loss of professionals opportunities across the life course individual level are largely driven trained in lower-income countries so that individuals arrive at older by ill health, hosts of demographic - to positions in higher-income coun age in a healthier state (Fried and and nondemographic factors are tries (Aluttis, Bishaw, and Frank, Paccaud, 2012). Such health care driving costs for the entire health - 2014). models would need a multidisci system. Aging is just one of the plinary team to deal with diverse Increasingly though, populations demographic contributors; others health needs, including increasing are demanding that better health include urbanization, migration, illness complexity, disability, and and family/household structures. services be provided without frailty. causing financial hardship: the Numerous nondemographic factors top priority of African and Asian contribute to health care costs, HEALTH SYSTEM’S including technological advances respondents to a recent UN survey RESPONSE TO AGING IN in health care, increasing use of (Kruk, 2013). Beyond provision of LOW- AND MIDDLE-INCOME a public good, governments may technology, and higher female COUNTRIES employment levels—resulting in gain public trust as a result of The competition for resources is less informal (unpaid) caregiving improving health system access strong in all countries—albeit, at (Rechel et al., 2009). While some - and performance (Rockers, Kruk, different starting points in terms what limited data are available, and Laugesen, 2012). of level of existing infrastructure, the current evidence suggests that human resources, and available HEALTHCARE COST FOR health costs are highest around the finances and mechanisms for cost- AGING POPULATIONS beginning and end of life in many sharing (Ali et al., 2013). The rate countries, and that the final 2 years A debate as robust as the ones of aging in lower-income countries before death consume around about lifespan limits and the com - today means that governments one-quarter of one’s lifetime health pression of morbidity (see Chapter will have less time to prepare than cost, regardless if one is young or 4) is raging about the role of aging higher-income countries have had old (Economist Intelligence Unit, populations on increasing health - in the past. Fortunately, interna 2009; Ji-yoon, 2010). Nonetheless, care costs (Peterson, 1999; Wallace, - tional attention to achieving uni - and noting the limitations of avail 1999; Heller, 2006; McKee et al., versal health care has the potential able research, at the population 2009; The Economist, 2009; Bloom to stimulate national political will, level and removing proximity to et al., 2015). Despite the fact that as well as financial and technical death, longer life does not neces - increased longevity underscores assistance. sarily correlate with higher health one of the most remarkable human expenditure, (Felder, Zweifel, and Regarding infrastructure, few low- success stories of any era, there Werblow, 2006; Seshamani and and middle-income countries have are serious concerns about the Gray, 2004; Felder, Werblow, and vital registration systems with high potential economic consequences Zweifel, 2010). coverage of deaths, a cornerstone of this global trend for rich and An Aging World: 2015 U.S. Census Bureau 70

81 percent (European Commission, out-of-pocket expenditures was Chronic conditions are, on average, 2015). considerably higher for poorer than typically more costly to treat than wealthier older adults (Figure 5-2). - acute, time-limited infectious dis COST IS ONE THING . . . Poor or near poor U.S. households eases. While older adults are more with older adults had 3 to 5 times likely to have chronic diseases, It is essential to reform the health higher out-of-pocket health care population aging alone has been care financing system when costs as a percentage of household found to contribute only a small - dealing with an aging popula 1 income than wealthier households. amount to health spending growth tion (Economist Intelligence Unit, Overall though, out-of-pocket (White, 2007; Martin, Gonzalez, 2009). It may well be that aging expenditures as a percentage of and Garcia, 2011; Xu, Saksena, and contributes only a small amount household income in the United Holly, 2011; de Meijer et al., 2013). to overall health care spending States was below the 2009 aver - Current evidence suggests that the growth in high-income countries. age for Organisation for Economic promotion of “healthy” or “active” Given the clear positive relationship Co-operation and Development aging may reduce lifetime health - between wealth and health spend (OECD) countries, suggesting a care expenditure (Dormont et al., ing at the country and individual considerable impact in many high- 2008; Suhrcke et al., 2008; levels, the association between income countries (Organisation Fried, 2011). aging and health expenditures for Economic Co-operation and may differ by level of country The contribution from population Development, 2011). development or by the wealth aging on overall health spending of individuals within countries. - remains difficult to clearly delin Even in high-income countries like eate. We do know that older adults 1 Out-of-pocket expenses for U.S. older the United States, the burden of adults depend on health status. are typically high users of care, this population group is growing in number, and per capita health costs continue to grow in many Figure 5-2. countries (de la Maisonneuve and Out-of-Pocket Health Care Expenditures as a Martins, 2013). A challenge for Percentage of Household Income by Age Group and governments will be to slow or Income Category in the United States: 2009 stop ever-growing health spending Low/middle/high income Poor/near poor as a proportion of gross domestic product (GDP) where population 23 23 22 aging is likely acting as a modest 21 cost driver (Appleby, 2013; OECD 2015). Encouragingly, the propor - tion of public-sector health spend - ing on older adults (as a percentage of GDP) did not change significantly in Canada between 2002 (44.6 percent) and 2012 (45.2 percent), 6 6 although there was considerable 5 4 variability across different regions in the country (Canadian Institute for Health Information, 2014). Furthermore, total aging costs as a 65+ 65–74 75–84 85+ percentage of GDP in the European Source: Federal Interagency Forum on Aging-Related Statistics, 2012. - Union have been revised down wards in recent forward projection analyses from 3.5 percent to 1.5 An Aging World: 2015 71 U.S. Census Bureau

82 In high-income countries, costs - end-of-life expenditures and expen from ongoing chronic care can be ditures for those not about to die, may also differ by type of care. An - especially debilitating for house otherwise future health costs will - example from Italy shows gener holds in low- and middle-income ally higher costs for primary care in be overestimated (ibid.). countries where a much higher per - centage of health costs are out-of- older adults than younger adults, Meanwhile, in middle- and low- - somewhat attenuated with proxim pocket, compared to high-income income countries, demographic countries; however, considerable ity to death (Figure 5-3), but also and epidemiological shifts are notes higher inpatient costs for challenges remain for the uptake of creating higher costs for care and younger adults than older adults health insurance in these settings financing systems not yet adapted (Schieber et al., 2006; Acharya et (Atella and Conti, 2014). A study to providing the type of chronic - in New Zealand with more com al., 2012; Kruk, 2013). care required at a reasonable cost. - prehensive health system spend At the individual level, the burden In a number of middle- and low- ing data also found wide variation income countries, a long lag exists of noncommunicable diseases is in costs by age (with costs per in increasing per capita health already large for the adult popu - person-year highest at age 0 and lation overall and may start at expenditure in line with growth in ages 80 and over), but the varia - national income. Even so, a system earlier ages in many lower-income tion was substantially less among countries, providing additional overall that views chronic disease people within 6 months of death rationale to start reconfiguring - management as serial acute epi (Blakely et al., 2014). With rising sodes necessitating more interac health systems sooner rather - life expectancy, projections of tion with care providers is not a than later (Engelgau et al., 2011; health spending should separate Robinson and Hort, 2012). Costs sustainable arrangement (Allotey Figure 5-3. Predicted Quarterly Primary Care Costs by Time to Death and Age in Italy: 2006–2009 Euro per quarter 350 300 Ages 71 to 75 250 Ages 61 to 65 Ages 76 to 80 Ages 66 to 70 200 Ages 56 to 60 150 100 50 0 5 16 4 3 2 1 15 14 13 12 11 10 9 8 7 6 Time to death (quarters) Source: Atella and Conti, 2014. Adapted from Figure 1. An Aging World: 2015 U.S. Census Bureau 72

83 facility services are out-of-pocket et al., 2011; McKee, Basu, and . . . ABILITY TO PAY IS Stuckler, 2012). From a systems for U.S. older adults covered by ANOTHER perspective, inequalities in health Medicare insurance (Figure 5-4). When faced with health care worker distribution within coun - costs, a large portion of the global While not guaranteed, provisions tries are often significant. Without population do not benefit from for health care in older age are incentives, health professionals will cost sharing schemes, such as more often available for those liv - - remain concentrated in urban cen health insurance, that would defray - ing in countries with social protec ters, while many older people will potentially impoverishing health tion systems, or with universal care continue to live in rural settings expenses (Saksena, Hsu, and schemes. Those without insurance even with current urbanization Evans, 2014). These individuals coverage or not living in countries trends. Financing of health systems and households may delay or forgo with social protection schemes is an increasing concern for econo - needed health care. This happens are forced to rely on alternative mies as a whole when considering more often in lower-income coun - financing mechanisms. These cop - the growth in overall population tries where formal health insurance ing mechanisms provide important sizes, the benefits of universal is rare, but cost and access are also - information about how house coverage, and the need to provide a concern for poorer and vulnerable holds deal with payments and also social protection in older age. The populations in high-income coun - income loss from inability to work costs and financing of care should tries. A high percentage of costs for (Leive and Xu, 2008). For example, be examined in light of all drivers drug, dental, and long-term care almost 26 percent of households of health spending, not just aging. Figure 5-4. Source of Payment for Health Care Services by Type of Service Other for Medicare Enrollees Aged 65 and Over in Out-of-pocket the United States: 2008 Medicaid Medicare Percent 100 80 60 40 20 0 Inpatient Hospice Home Short- All services Long Physician/ Out- Dental Prescription drugs patient -term medical hospital term health hospital care facility care institution Note: "Other" refers to private insurance, Department of Veteran's Affairs, and other public programs. Source: Federal Interagency Forum on Aging-Related Statistics, 2012. An Aging World: 2015 73 U.S. Census Bureau

84 from 40 low- and middle-income costs, a strong positive correlation on the broader family and the is seen with long-term care costs countries borrowed money or sold household unit. Increased borrow - items to pay for health care (Kruk, and increasing size of the older - ing from family members and rela adult population. Long-term care tives suggests a need for financial Goldmann, and Galea, 2009). refers to services for persons who support or improved access to WHO’s SAGE also provides a recent have chronic, ongoing health and risk pooling for health care costs. look at the microeconomic impact Formalized solutions which address functional dependency. Age and of aging on both households and this need, such as publicly funded disability are two main predictors individuals (He, Muenchrath, and - health care that is free or (highly) of long-term care need and expen Kowal, 2012). A larger financial ditures (Giovannetti and Wolff, subsidized at the point of use, can burden was seen in households alleviate the burden not only on the 2010; Olivares-Tirado et al., 2011; with members aged 50 and older individual but also on the extended de Meijer et al., 2013). While we in all six countries. Households household. know populations are aging, the with older adult members tended evidence about levels of current - to have higher rates of impov LONG-TERM CARE NEEDS and projected disability remains erishment and face higher rates AND COSTS WILL INCREASE unclear (Chapter 4). The percentage - of catastrophic payment experi - of those aged 65 and older receiv Long-term care use consists of a ence (Figure 5-5). These increased ing long-term care exceeded 15 broad continuum of care, use of demands on personal financial percent in seven OECD countries in which will undoubtedly increase resources resulted in increased 2011 (Figure 5-6). with population aging (Rechel borrowing from relatives and, et al., 2009). Unlike health care consequently, amplified the burden Figure 5-5. Financial Impacts of Having a Household Member Aged 50 and Over in Six Middle-Income Countries: 2007–2010 India Mexico Russia South Africa China Ghana 22.2 22.1 21.5 21.2 18.9 18.6 17.1 13.9 11.6 11.0 10.4 10.3 9.6 9.5 9.2 8.8 8.6 8.1 7.7 7.2 7.0 6.8 6.5 5.9 4.5 4.2 3.8 3.7 3.2 3.1 2.9 2.7 1.9 0.9 0.7 0.5 HH with no HH with HH with HH with no HH with HH with no member 50+ member 50+ member 50+ member 50+ member 50+ member 50+ Borrowed from relatives Impoverished by health Catastrophic health expenditure HH Household. Notes: A nonpoor household is considered to be impoverished by health payments when it becomes poor after paying for health care. Catastrophic expenditures are out-of-pocket payments of at least 40 percent of a household's capacity to pay nonsubsistence spending. For more information, see Xu et al., 2003. Source: Bloom et al., 2015. Adapted from Figure 5. An Aging World: 2015 U.S. Census Bureau 74

85 Figure 5-6. Percentage Receiving Long-Term Care Among Population Aged 65 and Over in Selected Countries: Circa 2011 Poland 0.8 Slovakia 3.2 3.4 Canada 3.7 Ireland 4.1 Italy Iceland 5.9 United States 6.4 6.4 Estonia 6.4 South Korea 6.7 Slovenia 7.2 Spain France 11.2 Hungary 11.2 Germany 11.7 Finland 12.3 Japan 12.8 Luxembourg 13.0 13.1 Czech Republic 14.5 Australia Sweden 16.3 16.7 Denmark Norway 17.4 17.6 New Zealand 19.1 Netherlands 20.3 Switzerland 22.1 Israel Note: Long-term care includes services provided at home or in institutions (nursing and residential care facilities which provide accommodation and long-term care as a package). Source: Organisation for Economic Co-operation and Development, 2013. U.S. Census Bureau 75 An Aging World: 2015

86 A wide range of funding sources are used for long-term care, with Figure 5-7. four common models: (1) a special Annual Growth Rate in Public Expenditure on long-term care insurance scheme, Long-Term Care (LTC) in Institutions and at Home in as in Germany, Japan, and South Selected Countries: 2005–2011 Korea; (2) general taxation, as Institution LTC Home LTC in Austria; (3) a combination of insurance, general taxation, and 1.0 Slovenia 4.3 private contributions, as in Greece; 1.3 3.5 Netherlands and (4) special programs, as in the Czech Republic 8.2 Netherlands (Chawla, Betcherman, 1.8 - and Banerji, 2007). Private cofund Hungary –1.6 1.9 ing also plays a role in almost all Denmark 3.1 2.2 European countries. However, the annual growth in public long-term Canada 3.2 2.5 care spending increased in most 3.1 Germany 1.7 OECD countries between 2005 1.7 Sweden 3.1 and 2011 (Figure 5-7); over the - same period, the growth in spend Austria 6.0 3.7 ing on institutional long-term care 4.5 Poland 11.6 decreased in Finland and Hungary. 4.8 8.1 Belgium Long-term care programs also Norway 4.9 6.4 differ in terms of whether they cover people needing such care 3.9 6.4 New Zealand at all ages or are limited to older –4.0 6.5 Finland people, whether there is means France 6.9 4.7 testing, the degree of cost-sharing, the scope and depth of coverage, 2.6 7.3 Japan and whether they support care by 4.0 Switzerland 7.6 family members or by trained and 8.0 4.0 Spain supervised staff (Tamiya et al., 2011). Regardless, there is sub - 8.7 16.6 Estonia stantial scope for better organiza - tion and coordination of services Source: Organisation for Economic Co-operation and Development, 2013. (Kendrick and Conway, 2006). Outside of wealthy countries, long-term care remains a neglected policy issue. The common view in lower-income countries relates to the primacy of family provision An Aging World: 2015 U.S. Census Bureau 76

87 of long-term care. This assumes breaking down—as young people “children who have come of age move to cities, more women enter have the duty to support and assist - continued material and nonmate their parents,” institutional elder rial family support in the face of the labor force, couples have care was virtually unknown until widely documented demographic fewer children, and intergenera - recent years (Feng et al., 2011). and economic shifts. In many tional spacing becomes greater. As a result of these realities, social However, some major cities have lower-income countries, although also in high-income countries, seen dramatic growth in elder care attitudes towards formal care in - homes operated by the city govern - these settings may already be shift longstanding assumptions about families taking care of older people, ing. In China, for example, where ment (Figure 5-8). the Constitution stipulates that including health care expenses, are Figure 5-8. Cumulative Growth in Elder Care Homes in Selected Chinese Cities: 1952 to 2009 Number of elder care homes 350 Beijing 300 250 200 150 Tianjin 100 Nanjing 50 0 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 1952 1955 1958 1961 1964 1967 Note: Elder care home is defined as a provider of institutional long-term care services licenced by the city government. Source: Feng et al., 2011. Adapted from Figure 2. An Aging World: 2015 77 U.S. Census Bureau

88 Box 5-2. Social Networks and Health Care Utilization In recent years, a wide range of technological innovations, such as robot nurses and telemedicine, has been developed in the United States, Europe, and Asia, to help care for older people (Economist Intelligence Unit, - 2009). While technology will undoubtedly play an increasing role in future health care systems, social interac tions and relationships remain one of the drivers of health, behaviours, and health care utilization worldwide. Social interactions and networks influence a wide range of behaviours and decisions in life, including some impacting health that are quite remarkable—from recovery after a heart attack and susceptibility to the common cold, to the dynamic spread of negative (smoking and obesity) and positive (happiness) factors for health (Berkman, Leo-Summer, and Horwitz, 1992; Cohen et al., 1997; Christakis and Fowler, 2007; Christakis and Fowler, 2008; Fowler and Christakis, 2008). Social integration also plays a considerable role in preserv - ing memory as we age (Ertel, Glymour, and Berkman, 2008; Wang, He, and Dong, 2015). Equally astonishing are recent findings about the role of social connectedness in disease pathways: experi - mentally induced inflammation in otherwise healthy women and men contributed to greater increases in depressed mood and feelings of social disconnection among women—suggesting a better understanding of sex differences in depression prevalence and a possible avenue for interventions (Moieni et al., 2015). One such health promoting intervention had a positive impact on social support and healthy lifestyle in a small sample of adults aged 60 to 73 in Tehran (Foroushani et al., 2014), and multiple interventions to reduce loneliness in older adults show promise (Cohen-Mansfield and Perach, 2015). Social isolation, on the other hand, has been shown to be detrimental to health in older adults, including higher all-cause mortality risk (Holt-Lunstad, Smith, and Layton, 2010; Shankar et al., 2011; Steptoe et al., - 2013). In another cohort of older community-dwelling adults, lack of social activity was associated with dis ability (James et al., 2011). Similarly, some social relationships have the potential for a health damaging effect in older adults (Seeman, 2000). Social relationships are critical for well-being in older adults and are also central to health maintenance over the life course. Reaching older age in better health, partly as a result of strong positive social relationships, would decrease health service needs and demands, yet the direct evidence behind the peer effect of social networks on health care utilization in older age is sparse (Wang, He, and Dong, 2015). Researchers in the United States showed how social relationships influenced the prevalence of having visited a dentist (Watt et al., 2014) and a significant association with health service demand (Wang, He, and Dong, 2015). A study in Canada found that social networks influence health care utilization through two main channels—sharing of information and social norms (Deri, 2005). How this extends to older people in lower income countries and the impact of social media remains to be determined. One challenge for all countries will be to identify an etiologic period clearly enough to know when to inter - vene. The follow-on challenge is how to construct an intervention in something as inherently complicated as social networks over a lifetime. An Aging World: 2015 U.S. Census Bureau 78

89 However, a number of factors hamper the development of long- Figure 5-9. term care programs including it Percentage of Population Aged 50 and Over Who being a low policy priority, a lack Report Being Informal Caregivers in Selected of disability data, and poor under - European Countries: 2010 standing of the extent and changes in informal support systems. The 11.8 Denmark extent of neglect on this topic was clearly illustrated in a recent study 12.3 Sweden about the heavily skewed balance 12.8 of published research on the topic Poland favoring high-income countries 14.2 Spain (Lloyd-Sherlock, 2014). 14.6 Slovenia QUANTIFYING INFORMAL CARE AND CARE AT HOME 14.8 Switzerland Unpaid caregiving by family mem - bers and friends remains the main 15.6 Portugal source of long-term care for older people worldwide (Fernández et 15.7 Germany al., 2009). Yet it has a cost. At the 16.0 individual level, caregiving exacts France a considerable toll on the caregiver. 16.1 Austria For example, in rural India, older caregivers spent an average of 39 16.2 Hungary hours per week providing informal care with consequences for their 16.9 Netherlands own health and well-being (Brinda et al., 2014). In 11 European coun - 17.5 Estonia - tries, over 15 percent of the popu Czech lations aged 50 and over reported 17.7 Republic being informal caregivers in 2010 United (Figure 5-9). 18.2 Kingdom 19.7 Italy 20.6 Belgium Source: Organisation for Economic Co-operation and Development, 2013. An Aging World: 2015 79 U.S. Census Bureau

90 Older adults are not solely recipi and 16 percent care recipients in At the population level, efforts to - quantify the costs have helped to the group aged 75 and older, but ents of pensions or health and - nonetheless demonstrates giving long-term care. This population increase recognition of the impor tance of informal unpaid care. In and receiving even into older age. also provides a large proportion of care for other people, includ Informal care is more often pro - some cases, this has translated - vided by older women, many of into payment schemes for informal ing older adults and spouses. In - care, but more often has provided whom have higher levels of dis Canada, for instance, 34 percent ability and chronic conditions than - of those aged 55 to 64 were care insights into the types of sup men. Up to 71 percent of informal providers and 5 percent were port that can be given to informal care recipients (Figure 5-10). This caregivers in Hungary are women, caregivers to keep older people at while this drops closer to parity home. The value of informal care to shifted to 12 percent care providers the economy has been increasing, reaching $522 billion annually in a recent estimate from the United States (Chari et al., 2014). One Figure 5-10. particular condition, dementia, has Percentage of Canadians Providing Care to Older received attention because of its Population or Receiving Care by Age Group: 2014 increasing prevalence and the high Receiving care Providing care to older adult cost of care provision; and was 34 estimated to be around $200 billion in 2010 in the United States alone, with much of this cost borne by informal caregivers (Schwarzkopf et al., 2012; Hurd et al., 2013). A number of high-income countries 18 16 have moved to reduce expensive, formal institutional care while 12 increasing support for self-care and other services that enable 5 5 older people to remain in their own homes or a home-like environment (Coyte, Goodwin, and Laporte, 55 to 64 65 to 74 75 and over 2008; Häkkinen et al., 2008). Informal care may substitute for Source: Canadian Medical Association, 2014. formal long-term care in some cir - cumstances in Europe, particularly when low levels of unskilled care are needed (Bonsang, 2009). An Aging World: 2015 U.S. Census Bureau 80

91 in Denmark, where 54 percent of informal caregivers are women Figure 5-11. (Figure 5-11). Percentage of Women Among Informal Caregivers Aged 50 and Over in Selected European Countries: Improvements in the caregivers’ 2010 health status may mean that more older adults are able to provide 53.6 Denmark such care to a spouse or parent, United effectively enlarging the pool of 56.6 Kingdom potential caregivers. Additionally, a significant number of older people 58.2 Netherlands in many countries engage in vol- unteer work or help to look after 59.8 Belgium their grandchildren, providing an 60.6 important input into society that Slovenia would otherwise have to be pur - 60.8 Germany chased in the marketplace (Chari et al., 2014). 61.0 Austria OTHER CARE OPTIONS: 62.4 France RESPITE, REHABILITATIVE, PALLIATIVE, AND 63.0 Switzerland END-OF-LIFE CARE Czech A proportion of the older adult 63.5 Republic population is faced with heavier 63.8 burdens from poor health and ill- Sweden ness in older age that overwhelms 63.9 Spain informal care or does not fit easily within the bulk of formal care 64.2 Portugal structures. Additionally, otherwise - healthy older adults who need reha 64.6 Poland bilitative care after a health shock may face a trajectory of declining 65.6 Italy functioning and dependence if they fail to receive the care. These indi- 65.6 Estonia viduals, and often their families, need viable alternate types of care 71.0 Hungary such as rehabilitative, palliative, respite, or end-of-life care options. Source: Organisation for Economic Co-operation and Development, 2013. Further yet, a secular trend in higher-income countries has seen a steady increase in the proportion of deaths at home (Gomes, Calanzani, and Higginson, 2012). In these cases in particular, health promo- tion and universal care systems - require enough breadth to incor porate the idea of a good death (Kelly et al., 2009; Rumbold, 2011; Prince, Prina, and Guerchet, 2013; Davies et al., 2014). 81 An Aging World: 2015 U.S. Census Bureau

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101 CHAPTER 6. Work and Retirement For many individuals, the transi- For the countries shown in Table how workers prepare for a longer tion from work to retirement marks 6-1, labor force participation rates retirement period due to increased one of the most significant changes in 2012 for men aged 45 to 49 life expectancy has implications for that they will experience in their - were quite high—exceeding 90 per economic growth. lifetime. Increasingly, this transition cent in most countries. In general, LABOR FORCE occurs in stages and may involve the rates decline slightly for the PARTICIPATION RATES multiple entries into and out of the next older group aged 50 to 54. VARY SHARPLY BY AGE labor force. While labor force par - Rates continue to decline for each AND SEX ticipation declines as people age, successively older age group. By rates vary by sex and by level of ages 60 to 64, labor force par - The labor force is commonly economic development. Evidence ticipation rates were less than half defined to include those who suggests that the gap is narrow- the level for those aged 45 to 49 are either employed or seeking ing between men and women and in countries such as South Africa, employment. Typically, those who across countries. Tunisia, Italy, Russia, and Ukraine. perform unpaid work within a For men aged 65 and older, only household are not considered to Workers formulate expectations two countries had participation be part of the labor force, even about their lives after retirement rates exceeding 50 percent— though such work clearly has value but may find that circumstances Zambia and Guatemala. In Germany and would be expensive to replace beyond their control, such as and Italy, rates were less than 10 (Schultz, 1990). Those who want to official retirement ages and eco- percent for older males. work but have given up searching nomic cycles, affect their retire- for a job (“discouraged workers”) ment decisions. The recent Great For all countries in Table 6-1 labor are also considered to be out of the Recession of 2007–2009 led some force participation rates for women labor force. workers to delay retirement or to aged 45 to 49 were lower than come out of retirement and rejoin those of their male counterparts, The size of the labor force reflects the labor force while others retired although the gap was quite small not only economic conditions but earlier than planned (Burtless and in Russia and Ukraine. Less than also demographic factors, such as Bosworth, 2013). In addition to one third of women aged 45 to 49 the total population size and the the economic, psychological, and in Morocco and Tunisia were in the age distribution of the population. physical implications for indi- labor force. Similar to the trend For cross-country and cross-group viduals transitioning from work to for men, labor force participation comparisons, a more useful indica- retirement, there may be aggregate rates for women decline at older tor is the labor force participation effects on the overall economy age groups. For women aged 65 rate, which is the proportion of any and society. As traditional family and older, participation rates were particular population that is in the support erodes, new institutions below 20 percent in all countries labor force. emerge to address the needs of except Zambia (52.2 percent) and the older population. In addition, South Korea (23.0 percent). 91 An Aging World: 2015 U.S. Census Bureau

102 Table 6-1. Labor Force Participation Rates by Age and Sex in Selected Countries: 2012 (In percent) Women Men Country 50 to 54 45 to 49 55 to 59 45 to 49 60 to 64 65 years 65 years 60 to 64 55 to 59 50 to 54 years years years years and over years years and over years years Africa Morocco 95.3 89.1 79.8 51.1 ... 31.6 31.2 27.9 19.2 8.5 28.7 South Africa 42.9 82.6 31.8 N 62.1 54.3 66.1 18.7 N ... 75.6 Tunisia ... 88.2 70.1 34.4 15.4 23.5 16.6 11.5 4.8 1.9 94.1 Zambia ... 96.9 96.8 88.9 89.6 71.2 84.1 84.3 77.8 74.3 52.2 Asia Japan 64.6 96.1 75.4 28.7 75.7 73.4 92.2 45.8 13.4 ... 95.0 Malaysia 96.9 92.5 76.8 57.4 N ... 48.3 34.6 21.2 N 55.3 Singapore 73.4 95.6 88.5 74.6 ... 93.8 65.6 56.2 41.7 13.7 32.4 South Korea 62.5 ... 84.7 72.3 41.6 67.7 91.4 54.8 43.9 23.0 93.0 Europe Germany ... 93.9 91.6 85.7 58.9 7.1 85.3 81.9 73.3 41.1 3.3 Italy 1.4 91.6 89.5 74.1 32.7 ... 66.7 61.3 48.4 15.9 6.2 Russia 52.9 24.9 8.9 ... 92.6 88.7 77.8 38.5 14.1 90.6 84.3 Ukraine ... 66.7 32.2 20.5 83.2 73.5 78.2 25.9 16.7 85.2 34.7 Latin America/Caribbean Argentina 94.6 91.4 86.8 75.7 22.2 67.7 63.4 53.8 33.7 7.5 ... Brazil 30.0 91.6 86.1 78.2 62.0 11.7 67.4 58.8 45.5 30.0 ... Costa Rica ... 92.0 85.8 67.5 26.5 94.0 50.3 39.8 27.3 6.8 55.0 Guatemala 56.0 ... 96.5 92.9 90.0 66.4 96.2 51.8 44.7 36.3 15.0 Mexico 32.8 ... 94.9 91.8 85.4 71.5 42.8 55.4 50.2 41.5 15.5 Northern America Canada 8.8 78.9 ... 89.9 87.8 45.7 58.0 17.1 84.4 80.9 69.4 United States ... 84.1 78.0 60.5 23.6 88.1 73.7 67.3 50.4 14.4 75.6 Oceania Australia 78.5 ... 86.7 80.0 62.6 16.8 89.2 76.3 65.7 44.5 7.8 New Zealand 90.9 ... 91.5 15.0 88.2 77.6 25.5 82.3 82.8 77.4 64.1 N Not available. Note: For historical time series of labor force participation in these and other countries, see Appendix Table B-8. Source: International Labour Organization, 2014; ILOSTAT Database. women. At the other end of the spending that provide security for OLDER POPULATION scale, in Europe, less than 10 the older population (World Bank IN HIGHER INCOME percent of older men and less than Group, 2014). COUNTRIES LESS LIKELY TO BE IN LABOR FORCE 5 percent of older women were in In addition to substantial varia- the labor force. Clearly, the vast Sharp differences in labor force tion in labor force participation majority of the older population participation at ages 65 and above across world regions, there are in Europe spends their time on exist among regions of the world sometimes large differences among pursuits other than work. Europe’s (Figure 6-1). In 2010, older African countries within the same region. relatively low labor force par - men and women both had the In Africa, for instance, labor force ticipation rates are likely due to its - highest rates of labor force par participation of the older popula- substantial economic resources, ticipation—more than 50 percent tion in 2011 was below 15 percent policies that encourage early for men and over 30 percent for in Algeria, South Africa, Egypt, and retirement, and patterns of public An Aging World: 2015 U.S. Census Bureau 92

103 Figure 6-1. Labor Force Participation Rates for Population Aged 65 and Over Male by Sex and World Region: 2010 Estimate and 2020 Projection Female 2010 World (191 countries) 2020 2010 Africa 2020 2010 Asia 2020 2010 Europe 2020 Latin 2010 America and the Caribbean 2020 2010 Northern America 2020 2010 Oceania 2020 60 40 30 10 50 20 0 Percent Source: International Labour Organization, 2011; LABORSTA. 93 An Aging World: 2015 U.S. Census Bureau

104 The causal relationships between participation among the older Tunisia, and more than 70 percent - labor force participation and eco in Malawi, Mozambique, the Central population. In contrast, in lower income countries, the notion of - nomic development are often com African Republic, and Zimbabwe retirement may not make sense— plex. While developmental factors (Figure 6-2). the older population may need may lead to rises in female labor In general, countries with higher force participation, those employ - to continue to work, perhaps at a incomes per capita and more reduced level, until physically or ment patterns in turn contribute developed social security systems mentally unable to do so. to economic development. As tend to have lower labor force noted earlier, a key reason for the Figure 6-2. Labor Force Participation Rates for Population Aged 65 and Over for Selected African Countries: 2011 Malawi Mozambique Central African Republic Zimbabwe Tanzania Uganda Cote d'Ivoire Rwanda Kenya Ethiopia Nigeria Senegal Liberia Angola Niger Botswana Sudan Morocco Somalia Mali Libya Tunisia Egypt South Africa Algeria 100 90 80 70 60 50 40 30 10 0 20 Percent Source: The World Bank, 2013; World DataBank. An Aging World: 2015 U.S. Census Bureau 94

105 difference by sex concerns tradi Guatemala and Pakistan had the - with certain demographic charac - largest gaps at 42.6 percentage tional norms about the division of teristics, such as fewer children points and 45.3 percentage points, labor between males and females. (Contreras and Plaza, 2010). respectively. By 2012, the gender Female labor force participation GENDER GAP IN LABOR gap had increased for 18 of the at older ages may also reflect a FORCE PARTICIPATION countries and decreased for 16 gradual change in the perceived RATE IS NARROWING countries compared to an earlier value of wage earnings as year in the 1990s. The gap wid - subsequent cohorts realize the Globally, the gender gap in labor benefits of working longer ened in Guatemala, rising to 51.4 force participation narrowed in the (Fernandez, 2013). percentage points, and narrowed in - 1990s (decreasing by 1.8 percent - Pakistan, dropping to 31.0 percent age points) and then held constant Table 6-2 shows the difference age points. in the 2000s (International Labour in labor force participation rates Organization, 2012). Female labor between men and women aged LABOR FORCE force participation tends to be 65 and over for 34 countries in PARTICIPATION AMONG greater in more developed societ - the 1990s and in 2012. West THE OLDER POPULATION ies, among women less accepting European countries had some of CONTINUES TO RISE of traditional norms regarding the the smallest gaps between men IN MANY DEVELOPED division of labor between males and women (less than 5 percent - COUNTRIES and females, and among those age points) in the 1990s, while The size of the workforce relative to the number of pensioners can Table 6-2. have major implications for eco - Gender Gap in Labor Force Participation Rates for nomic growth and the sustainabil - Population Aged 65 and Over by Country: 1990s and 2012 ity of old age security programs. (Percentage point difference) From the 1950s to the mid-1980s, 2012 1990s Country an increasing share of older men France 0.3 1.5 ... exited the labor force in most 1.2 2.9 Belgium ... developed countries. Beginning Austria ... 2.4 3.8 in the 1990s, this trend reversed ... 3.8 Germany 2.8 Russia ... 3.9 5.2 (Kinsella and He, 2009). Labor force 5.8 United Kingdom ... 3.9 participation rates for older men 4.2 Italy 4.7 ... have continued to increase through 4.2 6.4 Mozambique ... the 2000s in many developed ... 3.5 Czech Republic 4.5 Australia ... 6.5 9.0 countries. Older women in these ... New Zealand 10.5 6.5 countries also experienced a rise in Denmark 6.1 6.7 ... economic activity over the past 2 4.7 6.8 ... Poland 7.0 ... 7.8 Sweden decades. 7.2 9.2 United States ... ... 3.0 Greece 7.3 A variety of factors have contrib - ... Canada 8.8 8.3 uted to this increase, including Israel 14.4 ... 11.8 uncertainty about the sufficiency 12.7 Uruguay ... 14.0 9.6 ... Zimbabwe 13.4 and viability of public pension 18.7 Singapore ... 14.4 systems, increased reliance on ... Argentina 18.7 14.7 defined contribution pension South Korea ... 18.8 18.6 Turkey ... 20.3 13.7 schemes, higher eligibility ages for 20.6 Japan ... 15.3 retirement benefits, and changing ... 20.9 22.9 Chile social norms favoring a later exit 21.9 20.8 Peru ... 21.8 ... Philippines 24.7 from the labor force (Friedberg 38.2 Jamaica ... 28.0 and Webb, 2005; van Dalen et al., Egypt ... 29.8 19.1 2010; Hurd and Rohwedder, 2011; Tunisia ... 30.5 13.5 27.3 37.9 ... Mexico Skugor, Muffels, and Wilthagen, 51.4 42.6 Guatemala ... 2012; Hasselhorn and Apt, 2015). Pakistan ... 45.3 31.0 All of these changes are driven to Note: Gender gap is male labor force participation rate minus female labor force participation rate. some extent by the fact that people Sources: International Labour Office, 2007, 2014; LABORSTA, ILOSTAT Database. An Aging World: 2015 95 U.S. Census Bureau

106 are living longer. For example, decision, which can be complex (males) and Figure 6-4 (females) for selected more developed countries. unless retirement ages rise along and hard to predict. Employment participation is affected by individ Countries that fall on the diagonal with increased life expectancy, - societies will bear the extra cost of experienced no change in labor ual level factors (such as personal a longer period of retirement (The force participation rates. For both and family health and personal men and women, most countries financial resources), work place Economist, 2011). This is especially are below the diagonal, reflecting the case in countries where old age factors (such as physical demands security systems are based on pay- - an increase in labor force participa of job and changing required skill set), and macro level factors (such tion. Among countries experiencing as-you-go (PAYGO) financing, which as the economic growth rate, a decline in participation rates for requires payroll deductions from older men were Greece, Japan, and retirement and pension policy, and current workers to provide benefits Poland. Countries with the largest to current retirees. changes in information and com - munication technologies). increases in participation rates for Although the factors mentioned both older men and older women - above tend to encourage later The change in labor force par included Australia, New Zealand, retirement ages, there are also ticipation rates at ages 65 and Sweden, and the United States. above between the 1990s and countervailing factors contribut - ing to an individual’s retirement 2012 is illustrated on Figure 6-3 Figure 6-3. Labor Force Participation Rates for Men Aged 65 and Over in More Developed Countries: 1990s and 2012 1990s Percent 36 Japan 30 24 18 United States Poland Canada 12 Sweden Greece New Zealand Denmark Australia Czech Republic United Kingdom Russia Italy 6 Germany Austria France Belgium 0 6 12 18 24 30 36 0 Percent 2012 Sources: International Labour Office, 2007, 2014; LABORSTA, ILOSTAT Database. An Aging World: 2015 U.S. Census Bureau 96

107 shown in Figure 6-3. Labor force Among less developed countries In countries with high employment participation rates for older women in the primary sector (agriculture shown in Figures 6-5 and 6-6, more and mining), participation rates experienced declines in labor force exceeded 50 percent in two less often remain high at older ages. developed countries (Mozambique - participation rates than experi enced increases from the 1990s When the scale of agriculture is and Zimbabwe) shown in Figure 6-6 but did not come close to this rate small with a large share engaged to 2012. Substantial differences in subsistence farming, family exist in participation rates between - in any of the more developed coun members often continue to work more developed countries and less tries included in Figure 6-4. into their 60s and beyond out of developed countries. For example, Demographic forecasts of labor economic necessity. As econo - - older males had labor force partici force participation rates among - mies develop and the service and pation rates that exceeded 50 per older adults are typically based industry sectors expand and cent in 2012 in six less developed upon recent trends, such as those countries (Guatemala, Jamaica, pension eligibility increases, the implied by Figures 6-3 to 6-6. labor force participation rate of the Mozambique, Peru, Philippines, Forecasts by the International and Zimbabwe) displayed in Figure older population typically declines Labour Organization (2011) imply 6-5 but did not reach this rate in from previous levels (Reddy, 2014; an increase in labor force par - any more developed countries Samorodov, 1999). ticipation for the older population Figure 6-4. Labor Force Participation Rates for Women Aged 65 and Over in More Developed Countries: 1990s and 2012 1990s Percent 36 30 24 18 Japan 12 United States Poland Greece 6 Canada France United Kingdom Italy Denmark New Zealand Sweden Australia Czech Republic Russia Austria Germany Belgium 0 0 6 12 18 24 30 36 Percent 2012 Sources: International Labour Office, 2007, 2014; LABORSTA, ILOSTAT Database. An Aging World: 2015 97 U.S. Census Bureau

108 Figure 6-5. Labor Force Participation Rates for Men Aged 65 and Over in Less Developed Countries: 1990s and 2012 1990s Percent 90 Mozambique 80 Zimbabwe Guatemala 70 60 Philippines Pakistan Mexico 50 Jamaica Peru 40 South Korea Turkey Tunisia China Egypt 30 Argentina Chile Uruguay 20 Singapore Israel 10 0 90 10 20 30 40 50 60 70 80 0 Percent 2012 Notes: The earlier year for Singapore is 2000. The later year for Pakistan and Zimbabwe is 2011 and for China, Jamaica, and the Philippines is 2010. Sources: International Labour Office, 2007, 2014; LABORSTA, ILOSTAT Database. decline through 2020 for both (both men and women) between to 2011 for all countries except men and women. In Asia and Latin 2010 and 2020 in more developed Portugal (Table 6-3). For the group aged 65 to 69, rates increased regions such as Oceania, Northern America and the Caribbean, the over the same period in all coun America, and Europe (see Figure - direction of projections is mixed. 1 tries except Greece, Poland, and In Asia, rates for older men are In contrast, labor force 6-1). participation rates in Africa, which - projected to decline while rates for Portugal. Increasing labor force par older women are expected to hold ticipation rates among the group are currently the world’s highest, are expected to continue a gradual steady. In Latin America and the aged 55 to 64 may suggest future Caribbean, older men are projected increases in participation rates for the older population. to see a slight decline while older 1 The International Labour Organization - (2011) generates projections of the economi women will see an increase. cally active population using a three-step SHARE OF THE OLDER, procedure, including application of extrapola - Increases in labor force participa - EMPLOYED POPULATION tion methods, changes in the business cycle, - tion rates in more developed coun - and judgement adjustments to achieve con WORKING PART-TIME sistency across gender and age groups. The tries are not confined to the older VARIES ACROSS COUNTRIES adjustments are based on the share of the population. Among 12 European population aged 0–14 and aged 55 and over, The labor force includes those who the share of the female population in total countries and the United States, population, share of immigrant workers in the are working (or seeking to work) participation rates increased for country, forthcoming changes in retirement full-time or part-time. Among older and preretirement schemes, other relevant those aged 55 to 64 from 2001 policy or legal changes, and HIV prevalence. An Aging World: 2015 U.S. Census Bureau 98

109 Figure 6-6. Labor Force Participation Rates for Women Aged 65 and Over in Less Developed Countries: 1990s and 2012 1990s Percent 90 Mozambique 80 70 Zimbabwe 60 50 40 Philippines 30 Guatemala South Korea 20 Peru Jamaica Mexico Turkey 10 Pakistan Argentina China Uruguay Chile Tunisia Israel Singapore Egypt 0 30 70 60 90 80 40 50 20 10 0 Percent 2012 Notes: The earlier year for Singapore is 2000. The later year for Pakistan and Zimbabwe is 2011 and for China, Jamaica, and the Philippines is 2010. Sources: International Labour Office, 2007, 2014; LABORSTA, ILOSTAT Database. workers, part-time work may be Table 6-3. attractive for a variety of reasons. Labor Force Participation Rates for Older Workers in Part-time work can provide older Selected Countries: 2001 and 2011 workers a stream of income and (In percent) allow them to maintain social con - Aged 65 to 69 Aged 55 to 64 Country nections with colleagues without 2001 2011 2001 2011 the daily demands of full-time Belgium 3.5 2.4 38.7 25.2 ... work. Part-time arrangements may Czech Republic ... 37.1 47.6 7.6 9.3 59.5 12.2 56.5 13.5 Denmark ... be especially attractive for older 5.3 11.8 Finland ... 45.9 57.0 workers who are already receiving France ... 30.7 41.4 2.1 5.3 a pension or have other financial 10.1 59.9 Germany ... 37.9 5.4 resources, which allow them to 8.6 10.3 Greece 39.4 38.0 ... ... 46.9 50.8 14.8 16.8 Ireland sequentially step away from the 37.3 ... 11.4 56.1 5.6 Netherlands workforce (Hannon, 2014). In Poland ... 29.0 36.9 10.8 9.4 general, part-time work is more Portugal 50.2 47.9 27.8 21.9 ... 4.5 ... 39.2 44.5 3.9 Spain common among older women than 1 32.1 26.1 United States 64.3 ... 61.9 older men. 1 Data for the United States is for 2002 and not 2001. Sources: Kritzer, 2013; Bureau of Labor Statistics, 2013. An Aging World: 2015 99 U.S. Census Bureau

110 2014). Among the older, employed Figures 6-7 and 6-8 show the engaged in part-time work than - employment status of older, population of men, the propor older, employed men (Figure 6-8). Among the same set of countries, employed men and women, tion engaged in part-time work as of 2013 ranged from under respectively, in a selection of 35 the proportion of older female workers employed part-time was countries. Across these countries, 20 percent in Greece, Latvia, women account for 33 percent Russia, and South Africa to over less than 20 percent in Greece only and exceeded 60 percent in 11 60 percent in Belgium, Germany, of older workers employed full- countries. time and 49 percent of older Luxembourg, the Netherlands, workers employed part-time in and Sweden (Figure 6-7). Overall, - The frequency of part-time employ employed women aged 65 and 2013 (Organisation for Economic ment among the older population Co-operation and Development, over showed higher proportions Figure 6-7. Employment Status of Employed Men Aged 65 and Over by Country: 2013 Full-time Part-time Netherlands Luxembourg Germany Belgium Sweden Austria Portugal Finland United Kingdom France Denmark Slovenia Australia Norway Poland Japan New Zealand Czech Republic Canada Ireland Slovakia Turkey Chile South Korea Hungary Mexico Italy Estonia Israel United States Spain Russia Latvia Greece South Africa 100 0 10 20 90 80 70 60 50 40 30 Percent Note: Part-time employment is less than 30 usual hours for main job. Source: Organisation for Economic Co-operation and Development, 2014; OECD Stat. An Aging World: 2015 U.S. Census Bureau 100

111 older workers may prefer to work is also related to the willingness of may indicate that when Greek retir - employers to allow part-time work. full-time but can only find part-time ees exit the labor force they do so employment. In a survey of 16 countries, the pro - without any sequential step-down to part-time work. Access to gener portion of employees saying that - While Greece showed very low ous pensions at retirement may their employer provided the option reliance on part-time work among allow more Greek workers to enter of part-time work to phase into the older employed population, retirement ranged from a high of total retirement once reaching age the labor force participation rate of 55 for public sector workers and 30 to 31 percent in Germany, India, older Greeks is among the lowest in and Sweden to a low of 16 to 17 age 60 for private sector workers the world. The large proportion of percent in Japan and Spain (Aegon, (Mylonas and de la Maisonneuve, older employees working full-time 2014). On the other hand, some 1999; Organisation for Economic Figure 6-8. Employment Status of Employed Women Aged 65 and Over by Country: 2013 Full-time Part-time Netherlands Germany United Kingdom Austria Sweden Ireland Belgium Finland Portugal Australia New Zealand Slovakia Denmark Luxembourg France Norway Canada Israel Poland Czech Republic Japan Slovenia Hungary Chile Mexico Turkey Estonia Italy South Korea Spain United States South Africa Russia Latvia Greece 0 10 20 100 90 80 70 60 50 40 30 Percent Note: Part-time employment is less than 30 usual hours for main job. Source: Organisation for Economic Co-operation and Development, 2014; OECD Stat. An Aging World: 2015 101 U.S. Census Bureau

112 reasons, including lack of data than remain unemployed for an Co-operation and Development, - availability, the nature of the busi 2007). The reluctance of Greek extended period even though their ness cycle, and definition differ - employers to offer part-time work preference is to remain in the labor force. At the same time, some older ences across countries. Economic could also be a partial explanation workers may delay their retirement for the rarity of part-time employ - upheavals may sometimes affect ment (van Dalen et al., 2010). to recover financially from the unemployment patterns across countries. A case study of the recession. UNEMPLOYMENT PATTERNS recent Global Recession of 2007– One comparison of 16 countries VARY ACROSS SEXES AND 2009 and its impact on unem - shows that unemployment lev - OVER TIME ployment patterns and retirement - els and patterns vary by coun patterns appears in Box 6-1. During Assessing levels and trends in try and timing relative to the economic downturns, older work - unemployment rates of older Great Recession of 2007–2009 ers may choose to retire rather people is challenging for multiple (Figure 6-9). For instance, the Figure 6-9. Unemployment Rate for Men and Women Aged 65 and Over by Country: 2005 and 2013 Men (In percent) Women 2013 2005 0.8 1.7 Australia 1.4 1.2 2.1 1.7 Chile 1.7 1.0 5.6 5.8 Colombia 4.5 4.7 Czech 2.8 1.2 2.0 3.4 Republic 0.7 0.6 Germany 1.2 1.0 0.7 Greece 10.8 3.6 5.8 1.0 1.3 Hungary 7.1 2.2 1.0 3.0 2.5 Japan 1.2 0.5 1.7 2.3 Mexico 0.8 1.4 4.0 3.1 Russia 4.3 2.6 7.4 4.7 Slovakia 11.8 4.7 3.0 South 1.6 1.0 1.3 Korea 0.4 1.7 6.4 Spain 3.6 6.2 0.9 1.5 Sweden 3.4 2.7 United 1.7 3.3 0.7 Kingdom 1.3 United 3.4 5.5 3.5 5.1 States Source: Organisation for Economic Co-operation and Development, 2014; OECD Stat. An Aging World: 2015 U.S. Census Bureau 102

113 unemployment rate for older men countries for men but declined for have higher unemployment rates women in 9 of the 16 countries). was higher than for older women than women aged 55 to 64 (Figure in both 2005 and 2013 in Chile, 6-10). Unemployment rates were The labor force aged 55 to 64 is substantially higher for both men Colombia, Japan, Mexico, South approaching retirement and their and women aged 55 to 64 in 2013 Korea, and the United Kingdom, unemployment status can affect the compared to 2005 for Greece and but the opposite was the case for financial security of future retirees; Czech Republic, Germany, Hungary, Spain. On the other hand, unem - - therefore, it is worthwhile to exam and Sweden. Older men were more ployment rates dropped notably ine this cohort as well. Estimates in 2013 compared to 2005 for likely to face an increase in the of the unemployment rate also are unemployment rate from 2005 to both men and women in this same likely to be more robust for this age - 2013 than older women (unem cohort in Germany. group. Among the same 16 coun - ployment rates rose in 11 of the 16 tries, men aged 55 to 64 tended to Figure 6-10. Unemployment Rate for Men and Women Aged 55 to 64 and Over by Country: 2005 and 2013 Men (In percent) Women 2013 2005 3.7 4.3 Australia 3.2 2.9 3.0 4.3 Chile 3.0 2.9 6.3 5.8 Colombia 5.8 5.4 1.2 Czech 4.5 5.4 2.0 6.3 6.4 Republic 0.7 12.0 6.1 1.0 Germany 13.0 5.2 3.3 16.4 Greece 4.7 15.9 4.3 8.6 Hungary 3.5 7.5 0.5 4.4 5.0 Japan 2.8 2.7 3.6 2.5 Mexico 1.4 1.1 13.1 10.6 Slovakia 11.6 13.8 South 2.8 3.1 1.2 1.6 Korea 5.7 20.3 Spain 7.5 19.7 5.4 5.8 Sweden 3.4 4.2 United 3.3 5.5 Kingdom 3.8 1.7 United 3.3 5.6 3.3 5.0 States Source: Organisation for Economic Co-operation and Development, 2014; OECD Stat. An Aging World: 2015 103 U.S. Census Bureau

114 Box 6-1. Impact of the Great Recession on the Older Population World markets experienced a general economic decline during the 2007 to 2009 period. While only a portion of the world’s countries saw negative growth rates for gross domestic product (GDP) during this time, many other countries faced slowdowns in their economic growth. In the United States, for example, a recession officially began in December 2007 and ended in June 2009. Nearly all member countries of the European Union also went into recession around the same time. China and India, on the other hand, did not enter recession but did experi - ence slowing economic growth (Bernanke, 2009). In addition, countries whose economies were less integrated with the world economy through trade or financial markets, such as many countries in Africa, were less directly affected. The International Monetary Fund estimated that real world GDP per capita (in purchasing power parity terms) declined in 2009 and stated that the world economy was experiencing a “Great Recession” more severe than at any time since the end of World War II (International Monetary Fund, 2009). The recession originated in the United States after a sharp decline in housing prices triggered defaults on sub - prime mortgages, the financial fallout from which spread to other parts of the world (International Monetary Fund, 2009). The recession was characterized by rising unemployment as well as falling prices of housing, commodi - ties, and other investments. To what extent did the recession affect the older population and have any effects lingered? The unemployment rates over the 2000 to 2013 period for four countries—Portugal, South Korea, United Kingdom, and United States—help illustrate the diverse impact of the Great Recession (Figure 6-11). Unemployment in the United States at ages 65 and over more than doubled between 2006 and 2010—from 2.9 to 6.7 percent, an increase of nearly 4 percentage points—before starting a slow decline and reaching 5.3 percent in 2013. The older labor force in South Korea and Portugal also saw a rise in unemployment levels following 2006 but at levels below those of the United States. However, while the unemployment rate peaked in 2010 for South Korea, the peak did not occur until 2012 in Portugal. In the United Kingdom, unemployment rates fluctuated around 2 percent over the entire 2000 to 2013 period for the older population. While unemployment rose for the older population, they were lower than the rates of younger adults (aged 25 to 54) in each of the four countries. South Korea did not experience sharp fluctuations in unemployment for the population aged 25 to 54 through - out the period. Unemployment rates among younger adults largely flattened in the United Kingdom after 2009 and continued to rise in Portugal after 2008, reaching 15.5 percent in 2013. The lack of notable improvement in unemployment rates in Portugal and the United Kingdom likely reflect the subsequent public debt crisis and implementation of austerity measures in Europe, in contrast to a decline in U.S. unemployment after 2010. The retirement plans and wealth of the older population in the countries most impacted by the Great Recession were also affected by the declines in asset prices—in particular housing and financial investments. In Denmark, Ireland, the Netherlands, and Spain, for example, real housing prices declined by 25 percent or more (International Monetary Fund, 2015). In the United States, housing prices also declined although older Americans tended to have greater equity accumulated prior to the housing collapse than did younger home owners (West et al., 2014). One study focused on American preretirees aged 53 to 58 in 2006 found that their net housing wealth declined by 23 percent in real terms between 2006 and 2010, although their total wealth declined only 2.8 per - cent from 2006 to 2010 (Gustman, Steinmeier, and Tabatabai, 2012). While the Great Recession had a major impact on unemployment rates even among the older population, the trend of rising labor force participation rates among people aged 60 and older in more developed countries was not halted. A study of 20 Organisation for Economic Co-operation and Development (OECD) member countries found that the average rate of increase in labor force participation for those in the groups aged 60 to 64, 65 to Continued on next page. An Aging World: 2015 U.S. Census Bureau 104

115 Figure 6-11. Unemployment Rates for Population Aged 25 to 54 and Aged 65 and Over for Portugal, South Korea, United Kingdom, and United States: 2000 to 2013 Percent 16 Portugal 25 to 54 14 12 10 United States 25 to 54 8 United States 65+ 6 United Kingdom 25 to 54 4 South Korea 25 to 54 South Korea 65+ 2 United Kingdom 65+ Portugal 65+ 0 2001 2002 2003 2010 2000 2004 2005 2006 2007 2008 2009 2011 2012 2013 Source: Organisation for Economic Co-operation and Development, 2014; OECD Stat. 69, and 70 to 74 accelerated in more than half of the 20 countries since the onset of the Great Recession (Burtless and Bosworth, 2013). The trend of a labor force participation rate increase for workers aged 60 and over slowed significantly in only three of the 20 countries—Greece, Portugal, and Ireland—countries that experienced particu - larly severe recessions (ibid). Overall, the Great Recession motivated some older workers to postpone retirement and drew others back into the labor force. Lastly, given the many modifications to world social security systems observed between 2008 and 2013 (Organisation for Economic Co-operation and Development, 2013), one may ask whether the Great Recession pro - vided a catalyst for such changes. The answer is not entirely straightforward. Many social security systems were quite generous and financially unsustainable before the Great Recession and likely in need of reform even if the recession had not occurred (Capretta, 2007). However, the Great Recession may have contributed to the substan - tial reform packages introduced in OECD countries and helped to revise thinking about who should be covered and what is affordable (Organisation for Economic Co-operation and Development, 2013). Note: For example, the labor force participation rate of 65- to 69-year-olds increased at an average rate of 0.1 percentage point per year between 1989 and 2007 but at an average rate of 0.8 percentage point a year between 2007 and 2012 for the 20 sample countries. An Aging World: 2015 105 U.S. Census Bureau

116 survey of 12 countries found that preclude further work even EXPECTATIONS AND potential differences between on a part time basis or favorable REALITIES—MANY financial circumstances that allow - expectations of workers and reali WORKERS UNCERTAIN ABOUT THEIR LIFESTYLE ties experienced by retirees in 2013 them to avoid it (Aegon, 2013). AFTER RETIREMENT AND The discordancy may also reflect (Figure 6-12). A minority of workers MANY RETIRE EARLIER the cohort difference between cur - (34 percent) in these 12 countries THAN EXPECTED rent workers and current retirees. said they planned to stop working altogether and enter full retirement. Thus, if current workers expect an In the transition from work to Such expectations contrast with the - increasingly tenuous future for pub retirement, some workers prefer realities of current retirees, among lic social security systems or simply a gradual “step down” to retire - whom 57 percent stopped working want to continue working to later ment, while others wish to move entirely after retirement. ages, their plans to continue work - - from full-time employment imme ing part-time may differ from that diately into full-time retirement. These discordant findings likely of current retirees (Organisation Increasingly, the gradual transi - reflect unforeseen circumstances for Economic Co-operation and tion model is being preferred by that individual retirees often Development, 2013). workers in developed countries encounter, such as health problems (Hasselhorn and Apt, 2015). One Figure 6-12. Work Plans After Retirement by Workers and Retirees for Selected Countries: 2013 (In percent) Current workers selecting "I will immediately stop working altogether and enter full retirement." Current retirees selecting "I immediately stopped working altogether and entered full retirement." 74 68 67 64 59 59 58 57 54 51 51 49 48 45 44 43 39 38 36 34 31 28 25 24 23 22 Germany All United Japan China France Spain United Hungary Nether- Poland Sweden Canada lands respondents States Kingdom Notes: The question for workers was "Looking ahead, how do you envision your transition to retirement?" The question for retirees was "Looking back, how did your transition to retirement take place?" Source: Aegon, 2013. An Aging World: 2015 U.S. Census Bureau 106

117 Such differing opinions likely Workers’ preferences for when to in Canada and China seemed to be reflect circumstances specific to more optimistic (low proportions retire and which transition model each country as well as subjective to follow are influenced by their who lack confidence about having interpretations about what exactly a comfortable lifestyle in retire - expected financial security in retire - would constitute a comfortable ment. Workers around the world ment), whereas about two-thirds or lifestyle in retirement. Confidence more in France, Hungary, Poland, express varying opinions about and Spain were not confident about about a comfortable retirement how comfortable they expect their lifestyle will be upon retirement. may also be related to the gen achieving a comfortable lifestyle in - retirement (Figure 6-13). Among the 12 countries included in eration that each cohort was born the Aegon (2013) survey, workers into, including the circumstances Figure 6-13. Workers Who Are Not Confident About Having A Comfortable Lifestyle in Retirement by Country: 2013 85 (In percent) 74 66 65 57 52 50 49 45 41 40 33 20 Nether- Hungary Germany United Spain Poland France All Japan United China Sweden Canada respondents States lands Kingdom Notes: The question was "Overall, how confident are you that you will be able to fully retire with a lifestyle you consider comfortable?" Not confident includes those responding “not at all confident” or “not very confident.” Source: Aegon, 2013. 107 An Aging World: 2015 U.S. Census Bureau

118 encountered at primary working younger generation of Millennials STATUTORY RETIREMENT ages as well as those encountered seemed more optimistic (Figure AGES VARY WIDELY ACROSS - 6-14). Such differences might sim (or envisioned) at retirement. In the WORLD REGIONS, YET TEND TO LUMP AT CERTAIN AGES - United States, the Baby Boom gen - ply reflect intergenerational differ eration (born between mid-1946 to ences of hope and experience—the When workers are asked to evalu - challenges foreseen during retire - 1964), which is already in retire - ate their prospects upon retire - ment or closest to it, seemed more ment may seem easiest to resolve ment, one of the first concerns an by those furthest from it. pessimistic about their standard of individual may have is the age at living after retirement, while the which s/he will qualify for a public pension. The statutory retirement age for social security programs Figure 6-14. varies widely across the world Workers' Expectations Regarding (Figure 6-15), reflecting any num - Not sure Standard of Living in Retirement in ber of local factors, such as life Decrease the United States by Generation: 2014 Stay the same expectancy and available budgets. Increase Among many other considerations, Percent 100 it is often claimed that increases in the official retirement age will 90 result in more youth unemploy - ment, although empirical studies 80 in OECD countries have questioned 70 whether such a connection truly exists (Böheim, 2014). 60 The youngest statutory retirement 50 ages (ages at which retirees are - eligible to receive a social pen 40 sion) are in Africa, where less than 20 percent of countries specify 30 an eligibility age exceeding 60. In contrast, the share of European 20 countries with pensionable ages 10 above 60 exceeds 90 percent for males and 75 percent for females. 0 Despite such variation, Figure 6-15 Baby Boomer Generation X Millennials illustrates that statutory pension - Notes: The question was "Do you expect your standard of living to increase, decrease, able ages around the world tend or stay the same when you retire?" Millennials—born 1979–1996, Generation X—born 1965–1978, and Baby Boomer—born to continue to concentrate on the 1946–1964. exact ages 55, 60, and 65. Source: Transamerica Center for Retirement Studies, 2014. An Aging World: 2015 U.S. Census Bureau 108

119 Figure 6-15. Percentage Distribution of Statutory Pensionable Age by Region and Sex: 2012/2014 55 Between 55 and 60 60 Between 60 and 65 65 Under 55 Over 65 Male Africa (N=46) Female Male Asia (N=38) Female Male Europe (N=44) Female Latin America Male and the Caribbean Female (N=33) Northern Male America Female (N=3) Male Oceania (N=11) Female 20 80 100 40 70 90 0 30 60 50 10 Percent N=Number of countries in each region. Sources: Social Security Administration, 2013a, 2013b, 2014a, 2014b; Social Security Programs Throughout the World. Of course, the statutory pension- proportion of the population is at often been preferred (Organisation able age is subject to change. As older ages, but as the population for Economic Co-operation and noted earlier, official retirement ages and the older dependency Development, 2013). A number of ages have tended to rise in many ratio (retirees per worker) rises European countries and the United parts of the world (World Bank (Chapter 2), changes are needed. States are gradually increasing their Group, 2014). To remain financially sustainable, statutory pensionable age to 67. such systems require one or more For France, Germany, Spain, the Upward pressure on statutory of the following: increases in the United Kingdom, and the United retirement ages often occurs payroll tax for workers, cuts to States, pension eligibility will reach under PAYGO systems, which rely pensioner benefits, or a rise in the age 67 by 2022, 2029, 2027, 2028, - on payroll deductions from cur official retirement age. For many and 2027, respectively (Social rent workers to fund pensions of governments experiencing such Security Administration, 2014a; current retirees. Such systems are challenges, the latter option has 2014b). readily sustainable when a smaller 109 An Aging World: 2015 U.S. Census Bureau

120 Box 6-2. A Second Demographic Dividend?—Age Structure, Savings, and Economic Growth As fertility falls, a “demographic dividend” of more rapid economic growth might be achieved due to a higher proportion of the population at working ages (Chapter 3) and increased labor force participation of women. Conversely, the proportions of children and older adults—who tend to consume economic resources rather than produce them—will be lower. Yet the window of opportunity for reaping this potential benefit from changing age structure is temporary, and there is no guarantee that it will be reaped. Moreover, as fertility remains low for a long time, this initial dividend will dissipate as the large cohort of workers reaches older ages (Chapters 2 and 3). However, a second demographic dividend might also occur as a population ages and the age structure once again changes. Given longer expected lives and diminished traditional family support due to fewer children, workers may attempt to save more and accumulate additional assets in preparation for their retirement (Bloom, Canning, and Graham, 2003; Bloom et al., 2007). That extra savings and an increase in capital per worker due to a shrinking labor force may lead to rapid economic growth in contrast to the pessimistic view of the labor force shrinking, per capita income declining, and consumption and welfare falling (Mason and Lee, 2006; Bloom and Canning, 2008). - The opportunity to achieve the second demographic dividend will exist for many countries, but the realiza tion of that dividend will depend on how consumption of the older population is supported—through savings or borrowing, governmental transfers, or family transfers (Bloom and Canning, 2008). Economic policies that encourage workers to save and accumulate assets such as housing, businesses, and funded pensions will be important. A developed financial system and access to global markets are key to providing opportunities for workers to achieve financial independence in old age and reduce reliance on families and the government. If governments choose to increase PAYGO public pensions in response to population aging, then this will coun - ter saving incentives and substantially increase the burden on younger generations (ibid.). Japan, one of the most rapidly aging countries in the world due to a dramatic decline in fertility in the 1950s and mortality improvements that have placed Japan ahead of nearly all other countries in terms of life expec - tancy, is the first Asian country to begin reaping the second demographic dividend. The second dividend contributions to growth in Japan were high in the 1980s (adding nearly 1.5 percentage points to economic growth), while in more recent years the benefits are more modest—adding about 0.5 percentage point to growth (Ogawa et al., 2010). The traditional family support system is disappearing due to fewer children and increased public pension benefits. One statistic illustrates the change—in 1950 nearly two-thirds of Japanese married women said they intended to rely on their children for old age support but in 2000 only 11 percent expected to depend on their children (Ogawa, Kondo, and Matsukura, 2005). While Japan has increased spending in support of the aging population, the government has set a ceiling of 45 percent of national income for the tax burden for financial social security programs (ibid). The government hopes that increas- ing financial literacy rates among adults in Japan will further increase life cycle saving among workers and continue the second demographic dividend (Ogawa et al., 2010). An Aging World: 2015 eau U.S. Census Bur 110

121 Chapter 6 References Burtless, Gary and Barry P. Hannon, Kerry. 2014. “5 Part-Time Bosworth. 2013. “Impact of the Jobs for Retirees.” American Aegon. 2013. The Changing Great Recession on Retirement Association of Retired Persons. Face of Retirement: The Trends in Industrialized April. Aegon Retirement Readiness Countries.” Center for . Aegon and Survey 2013 Hasselhorn, Hans Martin and Wenke Retirement Research at Boston the Transamerica Center for Understanding Apt (eds.). 2015. College. Retirement Studies. Employment Participation of Capretta, James C. 2007. “Global Older Workers: Creating a _____. 2014. The Changing Aging and the Sustainability Knowledge Base for Future Face of Retirement: The of Public Pension Systems: An Labour Market Challenges . Aegon Retirement Readiness assessment of reform efforts Research Report. Federal . Aegon and Survey 2014 in twelve developed coun- Ministry of Labour and Social the Transamerica Center for tries.” Center for Strategic & Affairs and Federal Institute for Retirement Studies. International Studies, a report Occupational Safety and Health. of the Aging Vulnerability Index Berlin. Bernanke, Ben S. 2009. “Welcome project. Address Asia and the Global Hurd, Michael and Susann Financial Crisis.” In Reuven Glick Contreras, Dante and Gonzalo Rohwedder. 2011. “Trends in and Mark M. Spiegel (eds.), Asia Labor Force Participation: How Plaza. 2010. “Cultural Factors . and the Global Financial Crisis Much is Due to Changes in in Women’s Labor Force Proceedings of Asia Economic Journal of Population Pensions?” Participation in Chile.” Feminist Policy Conference held October Ageing 4/1-2: 81–96. 16/2: 27–46. Economics 19–20, 2009 Santa Barbara, International Labour Organization. California. 70 or Bust! The Economist. 2011. 2007. LABORSTA Why the Retirement Age Must Bloom, David E. and David Canning. Internet. Available at Go Up . A Special Report on 2008. “Global Demographic , Pensions. Change: Dimensions and accessed on October 20, 2007. Economic Significance.” Fernández, Raquel. 2013. “Cultural _____. 2011. Economically Active Populati and Development on Change as Learning: The Population, Estimates and Review 34: 17–51. Evolution of Female Labor Force Projections (6th edition, Participation Over a Century.” Bloom, David E., David Canning, October 2011). LABORSTA American Economic Review and Bryan Graham. 2003. Internet. Available at 103/1: 472–500. “Longevity and Life-cycle , of Economics 105: 319–338. Webb. 2005. “Retirement accessed on January 7, 2015. and the Evolution of Pension Bloom, David E., David Canning, Global Employment _____. 2012. Structure.” The Journal of Richard K. Mansfield, and . Geneva: Trends for Women Human Resources 40/2: Michael Moore. 2007. International Labour 281–308. “Demographic Change, Social Organization. Security Systems, and Savings.” Gustman, Alan L., Thomas L. _____. 2014. ILOSTAT Database. Journal of Monetary Economics Steinmeier, and Nahid Tabatabai. Available at , accessed on of 2007-2009 Affect the Wealth Böheim, René. 2014. “The Effect September 16, 2014. and Retirement of the Near of Early Retirement Schemes on Retirement Population in the International Monetary Fund (IMF). IZA World Youth Employment.” Health and Retirement Survey?” 2009. World Economic Outlook of Labor 70/June. Social Security Bulletin 72/4: . (WEO). Crisis and Recovery 47–66. Bureau of Labor Statistics. 2013. Washington, DC: IMF. Labor Force Statistics from the Current Population Survey. 111 An Aging World: 2015 U.S. Census Bureau

122 _____. 2015. “Housing Recoveries: Ogawa, Naohiro, Makoto Kondo, Social Security Administration. Cluster Report on Denmark, and Rikiya Matsukura. 2005. 2013a. Social Security Programs Ireland, Kingdom of the “Japan’s Transition From the Throughout the World: Africa, Netherlands — The Netherlands, Demographic Bonus to the . Office of Retirement 2013 IMF Country Report and Spain.” Demographic Onus.” Asian and Disability Policy. Office 15/1. Population Studies 1/2: of Research, Evaluation, and 207–226. Statistics: SSA Publication Kinsella, Kevin and Wan He. 13-11803. An Aging World: 2009. Organisation for Economic 2008 . International Population Co-operation and Development. Social Security _____. 2013b. Reports, P95/09-1, U.S. Census 2007. OECD Economic Surveys: Programs Throughout the Bureau. Washington, DC: Greece 2007 . Paris: OECD World: Asia and the Pacific, U.S. Government Printing Office. Publishing. . Office of Retirement 2012 and Disability Policy. Office Kritzer, Barbara E. (ed.). 2013. Pensions at a Glance _____. 2013. of Research, Evaluation, and “International Update: Recent 2013: OECD and G20 Indicators . Statistics. SSA Publication Developments in Foreign Paris: OECD Publishing. 13-11802. Public and Private Pensions.” _____. 2014. OECD.Stat . Available Social Security Washington, DC: Social Security _____. 2014a. at , Programs Throughout the World: Administration. accessed on September 18, . Office of The Americas, 2013 Larsen, Mona and Peder J. 2014. Retirement and Disability Policy. Pedersen. 2012. “Paid Work Office of Research, Evaluation, Reddy, Bheemeshwar. 2014. After Retirement: Recent Trends and Statistics. SSA Publication “Labour Force Participation of in Denmark.” IZA Discussion 13-11804. Elderly in India.” Presentation Paper Series 6537, May. at Population Association of Social Security _____. 2014b. Mason, Andrew and Ronald Lee. America Annual Meeting 2014, Programs Throughout the 2006. “Reform and Support Boston: May 1–3. . Office of World: Europe, 2014 Systems for the Elderly in Retirement and Disability Policy. Samorodov, Alexander. 1999. Developing Countries: Capturing Office of Research, Evaluation, “Ageing and Labour Markets for the Second Demographic and Statistics. SSA Publication Older Workers.” International Dividend.” 62/2: 11–35. Genus 13-11801. Labour Office, Employment and Mylonas, Paul and Christine de Training Papers No. 33. Transamerica Center for Retirement la Maisonneuve. 1999. “The Studies (TCRS). 2014. The Schultz, T. Paul. 1990. “Women’s Problems and Prospects Faced Retirement Readiness of Changing Participation in by Pay-As-You-Go Pension Three Unique Generations: the Labor Force: A World Systems: A case study of Baby Boomers, Generation X, Perspective.” Economic OECD Economics Greece.” and Millennials 15th Annual Development and Cultural Department Working Papers , Transamerica Retirement Survey 38/3: 457–488. Change No. 215, Paris: OECD Publishing. . TCRS 1171-0514. of Workers Skugor, Daniela, Ruud Muffels, and Ogawa, Naohiro, Andrew Mason, van Dalen, Hendrik P., Kène Tom Wilthagen. 2012. “Labour Amonthep Chawla, and Rikiya Henkens, Wilma Henderikse, Law, Social Norms and the Early Matsukura. 2010. “Japan’s and Joop Schippers. 2010. “Do Retirement Decision.” Network Unprecedented Aging and European Employers Support for Studies on Pensions, Aging Changing Intergenerational International Later Retirement?” and Retirement Discussion Paper Transfers.” In Takatoshi Ito 31/3: Journal of Manpower 11/2012-046. and Andrew K. Rose (eds.), 360–373. The Economic Consequences of Demographic Change in East . Chicago: University of Asia Chicago Press. An Aging World: 2015 eau U.S. Census Bur 112

123 West, Loraine A., Samantha Cole, The World Bank. 2013. World Bank Group. 2014. Global Daniel Goodkind, and Wan He. World DataBank, Africa Economic Prospects, Shifting 2014. 65+ in the United States: Development Indicators . Priorities, Building for the Future . . Current Population 2010 Available at , accessed on May 21, 2014. 113 An Aging World: 2015 U.S. Census Bureau

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125 CHAPTER 7. Pensions and Old Age Poverty The economic well-being of older The largest increase occurred dur - the older population often depends populations differs quite markedly ing the 1960s when the number of on other sources, such as families, throughout the world, as do the countries increased from 58 to 97. who may provide both monetary sources of income and support Another burst occurred during the and nonmonetary forms of support. that they receive. In most coun- 1990s. At present, 177 countries Various frameworks have been tries, a key source of income for have mandated pension systems of developed to organize these ele- the older population comes from one kind or another for their older ments of old age financial security, 1 public pension systems that rely on populations (Figure 7-1). such as the World Bank’s “5-pillar” pooled payroll taxes from current approach (Holzmann and Hinz, The purpose of these public sys- workers and employers, a pay-as- 2005). A portion of the older peo- tems is typically two-fold: to help you-go (PAYGO) type of financing. ple may not have sufficient means smooth out a stream of income, A smaller number of countries have to support themselves financially which would otherwise decline systems requiring contributions and, as a result, live in poverty. drastically following the transition to personal retirement accounts, from work to retirement, and to NUMBER OF COUNTRIES Provident Funds, or other pension reduce the incidence of poverty OFFERING A PUBLIC vehicles earmarked for each indi- (MacKellar, 2009). A diversity of PENSION CONTINUES TO vidual. Assets can also be accumu- programs has been developed to RISE lated through voluntary saving and meet these common goals. investment, sometimes encouraged As of 1940, only 33 countries by government programs that pro- in the world had public pension EARNINGS-RELATED vide favorable tax treatment. programs to support the welfare of PENSION PROGRAMS ARE the older population. Since then, STILL THE MOST COMMON In addition to these income the number of countries with such sources, the financial well-being of By far the most common public programs has steadily increased. old age pension program involves a periodic payment related to the level of earnings one had while working. Among the 177 countries Figure 7-1. that mandate a public pension, Number of Countries With Public Old Age/Disability/ Survivors Programs: 1940 to 2012/2014 more than 80 percent have an earn- 177 ings-related program (Table 7-1). 167 Among the six regions, those with the highest percentage of countries 135 having this type of pension are 123 Latin America and the Caribbean 97 (97 percent), Europe (89 percent), and Africa (85 percent). These mandated defined-benefit 58 44 pensions are based on a formula 33 that typically considers factors such as the level of earnings, years of service, and age at retirement, although earnings are usually 1940 1979 1989 2004 2012/2014 1949 1958 1969 Sources: 1940–2004 from Kinsella and He, 2009; 2012/14 from Social Security Administration, 1 According to the U.S. Department of 2013a, 2013b, 2014b, 2014c; Social Security Programs Throughout the World. State, there are 195 independent countries in the world and about 60 dependencies and areas of special sovereignty. Some dependen- cies have pension systems separate from their associated independent country. 115 An Aging World: 2015 U.S. Census Bureau

126 Table 7-1. Number and Percentage of Public Pension Systems by Type of Scheme and World Region Countries Individual Occupational Earnings with any pub- Provident Means- retirement Flat rate retirement lic pension tested fund related scheme scheme Region system - Per - Per Num- Num- Per - - Num- Per Per - Num- Num- Num- Per - Per Num- - ber ber ber cent cent ber cent ber cent ber cent cent ber cent 15 ... 177 100 144 81 46 26 62 35 16 9 9 5 26 All regions Africa ... 47 100 40 85 5 11 3 6 4 9 1 2 1 2 Asia 46 ... 100 28 61 15 33 11 24 12 26 2 4 5 11 Europe 27 45 100 40 89 19 42 ... 60 0 0 4 9 10 22 Latin America and the Caribbean 97 30 10 .. 33 100 32 0 4 12 18 55 0 0 0 Northern America 3 3 100 2 67 2 67 ... 100 0 0 1 33 0 0 Oceania 1 ... 3 100 2 67 0 33 0 0 0 0 1 33 0 Note: Countries may have more than one type of scheme. Data as of latest available year. Sources: Social Security Administration, 2013a, 2013b, 2014b, 2014c; Social Security Programs Throughout the World. capped in the computation of bene- Workers typically pay a percentage cases, by providing general rev- fits. The range of pensions paid out of covered salary and employers enue. However, the governments tends to be flatter than the range of contribute a percentage of covered of Bangladesh, Georgia, Botswana, payroll. The government often con- income among workers. and South Africa, for example, tributes by covering administrative pay the total cost of old age pen- Less common types of public old costs for the program and, in some sion programs in their countries age pension programs include flat- rate pensions (a uniform amount or based on years of service or Figure 7-2. residence), means-tested pensions Contribution Rates for Old Age Social Security (paid only to eligible retirees with Programs by Country and Contributor: 2012 and 2013 income or wealth below a desig- Employer Insured person nated level), provident funds (ben- Israel efits paid as a lump sum based on Honduras contributions and accrued interest), Indonesia and individual retirement schemes Ireland (benefits paid as an annuity or South Korea lump sum based on contributions Costa Rica and investment results). Some United States countries require that employers in Nigeria certain industries, such as railroad Saudi Arabia or mining, contribute to special Germany occupational retirement schemes Turkey for their employees. Argentina Uruguay Countries often have more than Finland one type of program. By region, flat Sudan rate and means-tested pension pro- China grams are most common in Europe India and Northern America, whereas Egypt provident funds are most common Italy in Asia. Hungary Regardless of the type of man- 25 30 35 40 0 5 10 15 20 datory, old age income security Percent program, funding comes from a Note: Old age social security programs includes old age, disability, and survivor's benefits. Sources: Social Security Administration, 2013a, 2013b, 2014b, 2014c; Social Security combination of worker, employer, Programs Throughout the World. and government contributions. An Aging World: 2015 U.S. Census Bureau 116

127 for each, although the share for with no contributions from work rights in any major public pension - employees is notably higher in ers or employers (Social Security scheme. Based on that definition, some countries such as Uruguay, high-income countries tend to Administration, 2013a; 2013b; have greater coverage. Coverage 2014c). in contrast to countries such as exceeds 90 percent of the labor Finland, Hungary, Italy, and China The required contribution amount force in Japan, United Kingdom, where the share for employers is varies widely throughout the world, United States, Australia, and Italy higher. from less than 2 percent in Israel to (Figure 7-3). In contrast, in the over 35 percent in Hungary (Figure PUBLIC PENSION COVERAGE world’s two population billionaires, 2 7-2). In between the extremes, GREATER IN HIGH-INCOME public pensions cover only 1 out of - contribution rates in other coun COUNTRIES 3 in China and 1 out of 10 in India. tries appear to be fairly evenly Although many countries have Such sharp international differences distributed. There are also differ - mandated public pension sys - - ences in the share of the contribu in coverage rates are often linked tems, their coverage of the over - to the proportion of people who tion between the employee and all workforce differs markedly. employer. In many countries, the work in the “informal economy.” The Organisation for Economic Those who work outside of the contribution amount is the same Co-operation and Development formal sector are far more chal - (2013b) has calculated coverage 2 - Contribution rates are not directly com lenging to cover administratively parable across countries because the earnings based on whether an individual using the wage-based criteria of subject to the rate can vary and a ceiling may contributed to or accrued pension exist on the earnings subject to the contribu - traditional social security systems tion rate. and, because of their lower income levels, they may have little or no resources available to contribute to the system (MacKellar, 2009). Figure 7-3. Proportion of Labor Force Covered by Public Pension In China, public pension schemes Systems in Each Country: 2005–2012 are limited to employees in urban enterprises (and urban institutions Japan managed as enterprises); the urban United Kingdom self-employed are covered only in United States - some provinces. The rural popula Australia tion is largely uncovered. In India, Italy the main pension scheme excludes Canada - an even larger swath of the popula France tion—the self-employed (urban as Germany well as rural), agricultural work - ers, and members of cooperatives Singapore with fewer than 50 workers (Social Korea Security Administration, 2013b). Hong Kong To address this major coverage Malaysia gap, India launched a new defined China contribution pension scheme (Atal Philippines Pension Yojana) in 2015 that offers Sri Lanka participants flexibility in contribu - Thailand tion levels, a guaranteed minimum Vietnam rate of return, and for those who Indonesia join in 2015, the government will India provide matching funds for the 40 90 60 20 10 0 100 50 70 80 30 next 5 years (India Ministry of Percent Finance, 2015). Note: Data refer to various years from 2005 to 2012 provided by each country. Source: Organisation for Economic Co-operation and Development, 2013a. An Aging World: 2015 117 U.S. Census Bureau

128 Box 7-1. Defined Benefit and Defined Contribution Pensions in Selected African Countries Unlike the shift from defined benefit to defined contribution systems in some parts of the world, in some African countries such as Ghana, Tanzania, and Zambia, the trend has been away from defined contribution - toward defined benefit or toward a combination of both (Stewart and Yermo, 2009). The nascent pension sys tems set up in former British colonies in Africa following independence were primarily defined benefit plans limited to civil servants and defined contribution provident funds for workers in the formal sector (Kpessa, 2010). Coverage was limited, and family and community were the primary sources of support in old age. However, with changing expectations and concerns about administrative management of large lump sum payouts, the steady stream of pension income under a more traditional defined benefit plan has become a more attractive option. This is especially so given the high fertility in Africa under which PAYGO financing is most viable. Ghana provides an illustration of such reforms. In years past, the primary mandatory pension system was called the Social Security and National Insurance Trust (SSNIT), which covered most civil servants and some workers in the private sector. The SSNIT relied on a partially funded PAYGO system with features of both defined benefit and defined contribution. A special feature allowed workers to collect 25 percent of their earned pension in a lump sum at the time of retirement (Steward and Yermo, 2009). As in many other African societies, however, coverage under the system is very low, only about 10 percent of the labor force. Although coverage remains very low today, a series of reforms implemented in 2010 helped to address inadequacies in the system for those who are covered. Workers are fully vested in a defined benefits program at age 60 with 15 years of service. Contribution rates are 5.5 percent of wages for employees and 13 percent for employers (Social Security Administration, 2013a). The lump sum payment of 25 percent of the pension at retirement was eliminated. The pension is 37.5 percent of the highest earnings over a 3-year period, with an additional 1.125 percent of earnings for each year worked beyond 15 years. In addition to early retirement provisions, those with insufficient years of service receive a lump sum. A smaller mandatory occupational pension scheme based on defined contributions and offering a lump sum payout covers another portion of workers (Stewart and Yermo, 2009). The Informal Sector Fund, established in 2008, consists of defined contribution schemes that are voluntary, based on individual contributions, and have no fixed contribution rate. These schemes target informal sector workers and as of 2013, there were 2 million participants (Van Dam, 2014). In contrast, Nigeria appears to have moved in the opposite direction, setting up a Chilean style system of mandatory individual retirement accounts in 2004 known as the Contributory Pension Scheme (Social Security Administration, 2013a). However, the new system has suffered problems similar to those experi - enced in other countries with the Chilean model, such as higher administrative costs compared to PAYGO systems and relatively low payouts (Ojonugwa, Isaiah, and Longinus, 2013). Given the potential drawbacks of both defined benefit and defined contribution systems, as well as the critical need for good governance and administration of both systems, some have suggested that Nigerian authorities consider a “social pen - sion” for the older population based on general tax revenues, much of which would be financed from profits in the oil industry (Casey and Dostal, 2008). In addition to coverage, another - 2013a). As is the case for cover total value of net expected pension important characteristic of public age, replacement rates tend to vary entitlements by total net earnings quite widely. Among the countries pension programs is the extent (adjusted for differences in income to which the pension “replaces” shown in Figure 7-4, replace taxes and social security contribu - - tions paid by workers and retirees; wages earned during the working ment rates exceed 100 percent in Argentina, the Netherlands, and years. One formula for calculating see Organisation for Economic Saudi Arabia (that is, the median the replacement rate divides the Co-operation and Development, An Aging World: 2015 U.S. Census Bureau 118

129 participation rate for residents aged 55 to 64 rose from 49.5 Figure 7-4. percent in 2004 to 68.4 percent in Public Pension Net Replacement Rate for Median 2014, and for residents aged 65 Earners by Country: 2013 to 69 increased from 18.9 percent (In percent) in 2004 to 41.2 percent in 2014 112.4 (103.9) Argentina (Singapore Ministry of Manpower, 109.9 (96.2) Saudi Arabia 2014). In addition, the government 103.8 Netherlands appointed a Central Provident Fund 94.9 Turkey Advisory Panel in 2014 to recom - 94.4 Hungary mend further reforms to provide 89.7 (70.8) China greater flexibility and improve 82.0 Italy retirement adequacy in the face of 72.4 (64.9) Russia increases in the cost of living and 72.3 France rising life expectancy. 68.7 (64.0) India 64.4 Canada 63.1 (57.4) OPINIONS DIFFER ON Brazil HOW TO IMPROVE 57.8 Germany SUSTAINABILITY OF PUBLIC 55.3 Sweden PENSION SYSTEMS 51.7 New Zealand 49.9 United States Upon first being established, 45.3 Mexico - earnings-related pension sys 42.5 Japan tems typically generate a surplus Indonesia 14.4 (13.2) because the size of the workforce 12.9 South Africa contributing is generally much larger than the pool of retirees who Notes: The net replacement rate is defined as the individual net public pension entitlement divided by net pre-retirement earnings, taking account of personal income have qualified to receive benefits. taxes and social security contributions paid by workers and pensioners. For countries Surplus payroll tax revenues can with different net replacement rates for men and women, the bar reflects the rate for men and the rate for women is shown in parentheses. either be banked for future retirees Source: Organization for Economic Co-operation and Development, 2013a. or used to fund other government spending. When surplus payroll tax revenue is not set aside for future retirees, as often is the case, earner can expect to receive more benefit level is low compared to the system becomes financed on other countries of similar wealth back during retirement than what a PAYGO basis. As the population (Organisation for Economic - they earned while working), com ages, a PAYGO system may run pared to less than 15 percent in Co-operation and Development, a deficit unless adjustments are 3 2012). As of 2011, the aver - Indonesia and South Africa. In 7 of made, and such adjustments may the 20 countries shown, the net age balance per member was provide a drag on the economy replacement rate for women and about equal to per capita income, (Holzmann, 2012; Organisation men is different, and in all cases which was viewed as inadequate for Economic Co-operation and the net replacement rate is lower given the high life expectancy in - Development, 2014b). For exam for women. Singapore (Asher and Bali, 2012). ple, based on current pension The Singapore government has benefits, the long-term contribu - Singapore is unusual in that it has a undertaken multiple initiatives to tion rate required will be over - single-tier pension system con encourage employment of older 30 percent of payroll in Pakistan sisting of a defined-contribution residents in recent years with and over 40 percent in China and plan administered by the Central some success. The labor force Vietnam (Organisation for Economic Provident Fund. While Singapore Co-operation and Development, has achieved nearly universal 3 Nonresidents (not citizens or permanent 2013b). - coverage of the citizen and per residents) accounted for 25 percent of the - population in Singapore in 2009 and 35 per manent resident labor force, the cent of the labor force (Asher and Bali, 2012). An Aging World: 2015 119 U.S. Census Bureau

130 than 15 percent by 2040. Among Figure 7-5 provides estimates and shown, 5 had pension and health projections of the total cost of pub - the countries in Figure 7-5, the costs equal to 15 percent or more of GDP in 2010, whereas 14 coun lic benefits provided to the popu - sharpest increases are projected - tries are expected to reach that - lation aged 60 and over—includ in South Korea and China, where ing both pension and health care share in 2040. The average cost of the share of GDP devoted to public such programs is expected to rise - benefits to the 60 and over popu programs—in 2010 and projected to 2040. Among the 16 countries from 10 percent of GDP to more lation will more than triple over the interval, due largely to the historic rapidity of fertility decline. However, China’s expenditures on Figure 7-5. the older population will remain Total Public Benefits to Population Aged 60 and Over well below the GDP share projected as a Percentage of GDP: 2010 and 2040 Projection for the United States and other wealthier countries. 2010 2040 With a shrinking share of work - Italy ers in the population, options to France ensure financial solvency of PAYGO systems (including PAYGO-funded Germany health care systems, such as Sweden Medicare in the United States) are Japan to: Spain • Raise the minimum age for United Kingdom benefit eligibility. • - Raise the payroll tax for work Poland ers and/or employers. United States Reduce benefits for recipients. • Switzerland Increase tax-funded subsidies • Netherlands or government borrowing to subsidize the system. Brazil Canada Opinions about which of these options is best for solving the Australia inherent challenges of a PAYGO sys - Russia tem may differ among workers and Chile retirees. Public opinion may also play a role in each country’s choices South Korea regarding the reform of public sys - China tems. A recent cross-national sur - Mexico vey of workers recorded opinions about possible policy options for India reforming public pension systems 20 15 25 30 5 0 10 (Aegon, 2013) with results shown Percent in Figure 7-6. Only a small share Note: Total public benefits include both pensions and healthcare. Source: Jackson, Howe, and Peter, 2013. An Aging World: 2015 U.S. Census Bureau 120

131 As to the acceptability of reduced - of workers felt that the govern asked to choose between reducing ment should do nothing and that pension benefits, raising pension benefits, there were also notable the public pension system would taxes, or a combination of reduced differences over specific options remain affordable (shares ranged pension benefits and increased for reducing them. For instance, about more than half of respon - from 1 percent in China to 14 taxes, the largest share selected dents in Germany and in Poland the balanced approach of both in percent in the Netherlands). When Canada, France, Germany, Japan, (Aegon, 2013) believed that people asked about options to increase already work long enough and the sustainability of government the Netherlands, Poland, the United Kingdom, and the United States. that the retirement age should not pensions, 4 percent of workers in China said they did not know be changed. In contrast, only 17 In both Spain and China, workers percent shared that belief in Japan favored raising pension taxes alone what the government should do, while one-third of respondents (ibid.). over reducing pension benefits or a combination of the two policies. in France did not know. When Figure 7-6. Favored Options to Increase Sustainability of Government Pensions by Country: 2013 Government should: Do nothing, Raise Reduce Balance a reduction Don’t know system will in pension benefits pension pension remain and an increase in taxes benefits pension taxes affordable Canada China France Germany Japan Netherlands Poland Spain United Kingdom United States 70 90 0 100 10 20 30 40 50 60 80 Percent Source: Aegon, 2013. 121 An Aging World: 2015 U.S. Census Bureau

132 - the 26 countries currently mandat expected to invest in broad catego - THE CHILEAN MODEL ing such accounts, 10 are in Latin ries or indexes of funds. UNDERGOES FURTHER America and the Caribbean and 10 REFORM AND SOME Between 2004 and 2009, the COUNTRIES ABANDON IT are in Europe (Table 7-1). proportion of the labor force con - COMPLETELY tributing to individual retirement Most of the Latin American and The Chilean government in 1981 accounts in Latin America increased Caribbean countries with mandated made a bold decision to abandon in 9 of the 10 countries, although individual accounts systems set its defined benefit public pension a large share of the labor force them up during the 1990s (Table 4 system and introduce a defined remained uncovered (Figure 7-7). 7-2). Under this system, workers contribution system administered In 2009, for instance, only Chile have some choice, albeit limited, by the private sector. Following the regarding the management of their and Costa Rica had more than 50 early success of Chile’s reforms, percent of the labor force con - retirement account. The number of other countries, many in Latin investment companies from which tributing to individual retirement America and the Caribbean and accounts while less than 20 percent individuals may choose ranges from Eastern Europe, followed the were doing so in Bolivia, Colombia, 2 to 15 per country, while the num - Chilean model and established ber of investment options offered El Salvador, and Peru. individual retirement accounts to by each company ranges from 1 to replace or supplement defined ben - 5 (Kritzer, Kay, and Sinha, 2011). 4 Argentina was the tenth country, and it efit public systems. At present, of Typically, investment managers are abolished individual accounts in 2009. Table 7-2. Characteristics of Latin American Individual Account Pensions: 2009 Allowable Contribution rates (percent) Number of pension fund Minimum investment Country Year system management rate-of-return fund types per company companies requirement Employee Employer began ... Bolivia 2 1 No 10.000 None 1997 Chile ... 1981 6 5 Ye s 10.000 Voluntary Colombia ... 1993 8 3 Ye s 3.850 11.625 1 Costa Rica ... 1995 5 1.000 No 3.250 Dominican Republic ... 5 1 Ye s 2.870 7.100 2003 El Salvador 1998 2 1 Ye s 6.250 4.050 ... Mexico ... 1997 15 5 No 1.125 5.150 Peru ... 1993 4 3 Ye s 10.000 None Ye s None 15.000 Uruguay ... 1996 4 1 Note: Uruguay employee contribution rate applied only to gross monthly earnings above 19,805 pesos. Source: Kritzer, Kay, and Sinha, 2011. An Aging World: 2015 U.S. Census Bureau 122

133 - - pension fund management compa The maturing Chilean model has and Slovakia, reduced contribu faced a number of challenges tions to the individual accounts, in nies were criticized for high fees some cases on a temporary basis. in Chile and many of the other and weak competition. For these countries fiscal deficits, countries that implemented this In response to these issues, aggravated by the global financial model over the past 30 years (Gill, countries have taken different Packard, and Yermo, 2005; Gill et crisis and the Maastricht limits, approaches, ranging from imple - al., 2005; Kritzer, Kay, and Sinha, - were a major factor in their deci - menting further reforms to weak 2011). It was the lack of financial sion. Chile, Colombia, Mexico, ening the individual accounts to sustainability inherent in the public Peru, and Uruguay have moved completely abandoning the Chilean PAYGO pension system, low cover - forward with a second round of model. Both Argentina (2009) reforms to strengthen their indi - age, and the potential higher rate and Hungary (2011) closed the of return to be earned in the private vidual accounts systems (Bucheli, individual accounts systems in Forteza, and Rossi, 2008; Kritzer, sector on retirement contributions their countries and transferred all that led Chile and other countries Kay, and Sinha, 2011). Chile led the workers back to the PAYGO defined - to switch to privately-managed way with a round of reforms imple benefit pillar. A number of coun - individual accounts. However, mented in 2008 (see Box 7-2). tries in Eastern Europe, including coverage remained limited and the Estonia, Latvia, Lithuania, Poland, Figure 7-7. Percentage of Labor Force Contributing to Individual Account Pensions by Country: 2004 and 2009 2004 2009 Percent 60 50 40 30 20 10 0 Mexico Costa Rica Chile Uruguay Argentina Bolivia Peru Colombia Dominican El Republic Salvador Source: Kritzer, Kay, and Sinha, 2011. An Aging World: 2015 123 U.S. Census Bureau

134 Box 7-2. Chile’s Second Round of Pension Reform Chile’s government appointed a council to review the pension system and recommend new reforms. The series of reforms enacted in 2008 were intended to increase participation rates, lower administrative costs, and improve the adequacy of pension benefits for all (Shelton, 2012). In order to address the issue of cover - age, participation of self-employed workers was transitioned from voluntary to mandatory. Several of the reforms focused on reducing the multiple, high administrative fees that participants faced. Prior to the 2008 reforms, the five pension fund management companies (Administradoras de Fondos de Pension) charged an average of 1.71 percent of earnings and several of the companies also charged fixed monthly fees (Kritzer, 2008). Reforms eliminated the monthly fixed administrative fees. The pension fund management companies now must bid and compete to manage the contributions of new labor force entrants with the selection going to the company submitting the lowest fees. The company must then maintain that fee for 24 months and offer the same low fee to all its account holders. Another change allowed insurance companies to set up fund management companies to compete with the existing companies. Reforms also gradually increased the share of foreign investments allowed to 80 percent of assets, up from 45 percent. The council concluded that Chile’s individual account system was working well for middle- and upper-wage earners who were regular contributors, but those who did not make regular contributions or made minimal contributions did not fare well (James, Edwards, and Iglesias, 2010). Thus, another pillar was added, Pension Basica Solidariato, to provide a basic pension to those who had not contributed to individual accounts or who would receive an inadequate pension based on their individual account balances. Reforms also sought to address gender inequities. Women had been particularly disadvantaged because of their shorter work history, lower earnings, and greater participation in the informal sector, which is not covered by the pension system. Women’s pensions were 30 to 40 percent less than men’s (Kritzer, 2008). The 2008 reforms introduced a pension bonus for each child that a woman had and the bonus will be added to her regular retirement pension when she reaches age 65. In addition, all widowers are now eligible for a survivor pension. Of course, incomes among the - population is shown for sev THE BIGGER FINANCIAL older population are not limited eral Organisation for Economic PICTURE INCLUDES OTHER Co-operation and Development to public pensions. In addition to SOURCES OF INCOME (OECD) countries on Figure 7-8. In mandatory government savings Clearly, every category of pen - programs, individuals may save 2011, public transfers represented sion schemes has its own benefits on their own. In some countries, over three-quarters of income for and limitations (MacKellar, 2009; the older population in Austria, voluntary saving is encouraged Holzmann, 2012; Cannon and Czech Republic, Finland, Greece, through favorable tax treatment, Tonks, 2013). Defined benefit plans such as 401K-type plans in the Ireland, Luxembourg, Portugal, become less viable as populations United States. There are also mul Slovenia, and Spain. In the United - age. Defined contribution plans States, only 38 percent of income tiple ways that individuals may tend to have limited coverage and among the older population came generate an income stream in their uncertain payouts for a large por - older years, including investments - from public transfers. The propor tion of the older population. Given tion of income from work earnings in rent-producing property and such limitations, many countries reverse home mortgages. Some varies among this grouping, from appear to be experimenting with 10 percent in Finland to 34 percent continue to work beyond age 65 multiple approaches to minimize (see Chapter 6). in the United States. While private risk (Organisation for Economic pensions and investment earnings Co-operation and Development, A more complete picture of constituted 28 percent of income in 2013a and 2014b). income sources among the older the United States, they represented An Aging World: 2015 U.S. Census Bureau 124

135 Figure 7-8. Income Distribution for Population Aged 65 and Over by Source and Country: 2011 Wage earnings Self-employed earnings Public transfers Private transfers and capital earnings Austria Czech Republic Estonia Finland Greece Iceland Ireland Italy Luxembourg Poland Portugal Slovak Republic Slovenia Spain United States 60 90 0 70 80 50 40 30 20 10 100 Percent Note: U.S. estimates are for 2012 and wage earnings includes self-employed earnings. Sources: Organisation for Economic Co-operation and Development, 2014a; Social Security Administration, 2014a. less than 5 percent in the Czech household saving rates (before basis. Using data calculated by the and after the implementation of Republic, Estonia, Greece, Poland, - OECD and collected in longitudi the pension reform). Attanasio and Slovakia, Slovenia, and Spain. nal surveys, Hurd, Michaud, and Brugiavini (2003) focused on the Rohwedder (2012) estimated the One important question is whether mean public pension replacement 1992 pension reforms implemented the receipt of income from one in Italy that reduced the present rate and relative financial wealth source may affect the effort to for 12 countries. They found that discounted value of the public save or earn income from another pension fund and found evidence for every extra dollar in expected source, a hypothesis known as pension income, the amount of of a displacement effect on private “crowding out” (Alessie, 2005). One saving. Attanasio and Rohwedder savings at retirement is reduced by approach to assess crowding out (2003) found substitution between 22 cents in the 12 countries (ibid.). is to compare expected income Another approach is to examine the United Kingdom public pension streams from mandatory pension the effect of pension reforms scheme and financial wealth at the plans with the amount of private time of reforms from 1975 to 1981. (involving a change in the expected savings on a country-by-country value of the public pension) on An Aging World: 2015 125 U.S. Census Bureau

136 can be rather complicated. For - Governments often offer prefer FAMILIES PLAY A MAJOR ential tax treatment for specific instance, in some societies, they SUPPORT ROLE IN MANY sources of income received by the may actually constitute a reverse SOCIETIES older population, such as pensions; transfer back to parents who had For generations, families have been - however, tax rates vary substan turned over their assets to one or key providers of both monetary and more children with the expecta tially across the world. Among the - nonmonetary support for the older tion that they would receive care in group of OECD countries shown population. In fact, a key strategy return. Despite these interpretive in Figure 7-9, for instance, the in traditional societies for ensuring challenges, one thing is clear—the average income tax rate paid by one’s security at older ages was to - those aged 65 and over ranged family provides important protec raise several children to adulthood from below 5 percent in the Czech tion from poverty for the older - (Schultz, 1990). However, as popu population. In India, for instance, Republic and Slovakia to above 20 lations become more urbanized and over three-quarters of the older - percent in Iceland. In all the coun fertility rates decline, the forms of tries shown in Figure 7-9, the older population live in three-generation family support for the older popula - households (Desai et al., 2010), an population has a lower average tax tion are changing. arrangement ideally suited to the rate than those at primary working The value of family contributions to ages. The lower average income sharing of assets and provision of the welfare of older people can be care for dependents. In the United tax rate for the older population challenging to estimate, since this States, family members often serve may reflect the lower income level can take the form of in-kind goods as long-distance caregivers for a of this age group in addition to and services, such as housing and favorable tax treatment. parent or relative living in another - daily assistance. The interpreta location (Clark, 2014). They tion of intergenerational transfers may help manage prescriptions, Figure 7-9. Average Income Tax Rate for Ages 18–65 and Over Age 65 by Country: 2011 18–65 Over 65 Tax rate 35 30 25 20 15 10 5 0 Portugal Italy Spain Greece Iceland Czech Estonia Finland Poland Ireland Slovakia Luxem- Slovenia Austria bourg Republic Source: Organisation for Economic Co-operation and Development, 2014a. An Aging World: 2015 U.S. Census Bureau 126

137 coordinate health care, ensure that bills are paid, arrange for home Figure 7-10. services, or assist with legal affairs. Poverty Rate for Total Population Besides the family, societies also and Population Aged 65 and Over Total population for OECD Countries: 2010 sometimes provide nonmonetary 65 and over sources of support, such as hous - ing subsidies, coupons for basic Czech Republic - foodstuffs, and coordinate volun Denmark teers providing free services. Iceland 2 Hungary PENSIONS CAN DRASTICALLY LOWER Luxembourg POVERTY RATES FOR THE Finland OLDER POPULATION Netherlands As noted earlier, one of the key Norway goals of mandated public pension Slovakia programs is to alleviate poverty France among the older population. Given Austria that older people are less likely to work, they are potentially more vul - Germany nerable than those at working age. 2 Ireland Comparing poverty rates across Sweden countries is challenging given Slovenia the variation in poverty measures 2 Switzerland and definitions. Poverty is defined Belgium - by the World Bank as “the pro nounced deprivation in well-being” United Kingdom (Haughton and Khandker, 2009). 2 New Zealand Typically, poverty is defined in Poland terms of resources needed to cover Portugal basic necessities such as food, Estonia shelter, and clothing. However, the Canada standard of well-being could also include capability to function in Italy society, which would involve access Greece to education, political rights, and Australia psychological support (ibid.). 1 South Korea The OECD calculated poverty rates Spain for its 34 member countries using 2 Japan - a relative poverty level of receiv United States ing income less than 50 percent 1 Chile of median equivalized household 2 Turkey disposable income (Figure 7-10). Under this poverty measure, 5 of Mexico the 34 OECD member countries Israel (Australia, Israel, Mexico, South 20 10 50 45 0 5 15 40 25 30 35 Korea, and Switzerland) had pov - Percent erty rates exceeding 20 percent for 1 Country data for 2011. 2 Country data for 2009. the older population. Note: Poverty is defined as income less than 50 percent of median equivalized household disposable income. Incomes are measured on a household basis and equivalized to adjust for differences in household size. Source: Organisation for Economic Co-operation and Development, 2013a. An Aging World: 2015 127 U.S. Census Bureau

138 rates for the population aged 65 and over exceeded 20 percent for Figure 7-11. Poverty Rate for Total Population and Population nearly half the countries (Bolivia, Aged 65 and Over for Latin America and the Colombia, El Salvador, Guatemala, Caribbean: 2005 to 2007 Honduras, Mexico, Nicaragua, and Total population 65 and over - Peru). However, in 14 of the coun tries, the poverty rate for the older Chile - population was lower than the pov erty rate for the total population Uruguay suggesting positive support for the Argentina - older population through govern ment programs. Costa Rica In Latin America and Caribbean Mexico countries, the average poverty rate Ecuador of those receiving a pension for the 18 countries is 5.3 percent, one- Brazil fifth of the average poverty rate of Dominican those not receiving pensions (25.8 Republic percent). Colombia shows the most Venezuela dramatic absolute difference in Paraguay - poverty rates between those receiv ing a pension and those without Panama a pension (2.4 percent vs. 51.4 Peru percent; Table 7-3). Uruguay shows the least difference (0.5 percent vs. El Salvador 3.0 percent). In Colombia about 15 Guatemala percent of the population aged 65 and over were receiving a pension, Bolivia while 84 percent were in Uruguay. Honduras The role of pensions in reducing - poverty among the older popula Colombia tion can be seen in Figure 7-12, Nicaragua where countries in Latin America and the Caribbean with higher pro - 20 40 35 30 25 50 45 10 5 0 15 portions receiving a pension tend Percent to have lower poverty rates overall. Note: Poverty line defined as US$2.50 per day purchasing power parity. While it may come as no surprise Source: Cotlear and Tornarolli, 2011. that poverty rates among older individuals who receive a pension income stream are lower than for - older population using an abso In a study of 18 countries in those who do not, the magnitude lute poverty line defined as daily Latin America and the Caribbean, of the gap in some of these coun - income of $2.50 in purchasing Cotlear, and Tornarolli (2011) tries is noteworthy. calculated poverty rates for the power parity (Figure 7-11). Poverty An Aging World: 2015 U.S. Census Bureau 128

139 Table 7-3. Population Aged 65 and Over in Poverty by Pension Status for Selected Countries in Latin America and the Caribbean: 2005 to 2007 (In percent) Poverty rate Country Percent Receive a pension receiving a pension Total No pension Uruguay 0.9 0.5 3.0 84.0 ... Chile 2.3 1.0 4.3 60.6 ... Brazil ... 1.5 14.3 84.4 3.5 Argentina 3.7 1.1 11.3 74.5 ... Dominican Republic ... 15.6 6.9 16.8 12.1 Ecuador 17.2 3.2 20.7 20.0 ... Paraguay ... 17.2 0.0 18.8 8.5 Panama 41.4 ... 18.2 1.9 29.7 Costa Rica 18.5 16.0 22.2 59.7 ... Venezuela ... 19.4 6.3 40.4 61.6 Peru ... 20.1 0.4 26.0 23.0 El Salvador 16.3 24.3 20.7 ... 2.2 Mexico 21.9 2.7 27.9 23.8 ... Bolivia ... 25.3 22.9 46.0 89.6 Guatemala 15.7 ... 29.1 8.2 33.0 Nicaragua 32.5 10.4 35.4 11.6 ... Honduras 37.1 ... 7.8 39.6 7.9 Colombia 14.5 51.4 ... 44.3 2.4 Note: Poverty line defined as US$2.50 per day purchasing power parity. Percentage receiving pension is derived algebraically from the first three columns. Source: Cotlear and Tornarolli, 2011. Figure 7-12. Poverty Rate Among Those Aged 60 and Over by Percentage Receiving Pension in Latin America and the Caribbean: 2005 to 2007 Percent receiving a pension 90 80 Brazil Uruguay 70 Bolivia Venezuela Argentina 60 Chile 50 Costa Rica 40 Panama 30 Mexico Peru 20 Ecuador El Salvador Guatemala Colombia Nicaragua Dominican Republic 10 Paraguay Honduras 0 35 5 10 40 45 15 20 25 30 Percent in poverty Note: Poverty line defined as US$2.50 per day purchasing power parity. Source: Cotlear and Tornarolli, 2011. An Aging World: 2015 129 U.S. Census Bureau

140 Chapter 7 References Cannon, Edmund and Ian Tonks. Haughton, Jonathan and Shahidur 2013. “The Value and Risk of R. Khandker. 2009. Handbook Aegon. 2013. The Changing Face Defined Contribution Pension on Poverty and Inequality . of Retirement: The Aegon Schemes: International Washington: The International Retirement Readiness Survey The Journal of Risk Evidence.” Bank for Reconstruction and 2013—Country Reports . Aegon and Insurance 80/1: 95–119. Development/The World Bank. and the Transamerica Center for Retirement Studies. Casey, Bernard H. and Jörg Michael Holzmann, Robert. 2012. “Global Dostal. 2008. “Pension Reform Pension Systems and Their Alessie, Rob J.M. 2005. “Does in Nigeria: How not to ‘Learn Reform: Worldwide Drivers, Social Security Crowd out Global Social from Others’.” Social Trends, and Challenges.” Private Savings?” In Peter De 8/2: 238–266. Policy Protection & Labor, Discussion Gijsel and Hans Schenk (eds.), Paper 1213, May. Washington, Multidisciplinary Economic: Clark. Jane Bennett. 2014. “How DC: The World Bank. The Birth of a New Economics to Manage Your Parents’ Care Faculty in the Netherlands . New Kiplinger’s Personal From Afar.” Holzmann, Robert and Richard York, NY: Springer. Finance . Hinz. 2005. Old-Age Income Support in the 21st Century: Asher, Mukul G. and Azad Singh Cotlear, Daniel and Leopoldo An International Perspective on Bali. 2012. “Singapore.” In Tornarolli. 2011. “Chapter 3, Pension Systems and Reform . Donghyun Park (ed.), Pension Poverty, the Aging, and the Washington, DC: The World Systems in East and Southeast Life Cycle in Latin America.” In Bank. Asia: Promoting fairness and Daniel Cotlear (ed.), Population sustainability . Mandaluyong Aging, Is Latin America Ready? Hurd, Michael, Pierre-Carl Michaud, City, Philippines: Asian Washington, DC: The World and Susann Rohwedder. Development Bank. Bank. 2012. “The Displacement Effect of Public Pensions on Attanasio, Orazio P. and Agar Desai, Sonalde B., Amaresh the Accumulation of Financial Brugiavini. 2003. “Social Security Dubey, Brij Lal Joshi, Mitali Assets.” Fiscal Studies 33/1: and Households’ Saving.” The Sen, Abusaleh Shariff, and 107–128. Quarterly Journal of Economics Reeve Vanneman. 2010. India Ministry of Finance. 2015. 118/3: 1075–1119. Human Development in India: Press Information Bureau, “Prime Challenges for a Society in Attanasio, Orazio P. and Susann Minister to Launch Pradhan Transition . New Delhi: Oxford Rohwedder. 2003. “Pension Mantri Suraksha Bima Yojana University Press. Wealth and Household Saving: (PMSBY), Pradhan Mantri Jeevan Evidence From Pension Reforms Gill, Indermit Singh, Truman Jyoti Bima Yojana (PMJJBY) and The in the United Kingdom.” Packard, and Juan Yermo. 2005. the Atal Pension Yojana (APY) on American Economic Review Keeping the Promise of Old 9th May 2015 at Kolkata.” 93/5: 1499–1521. Age Income Security In Latin Jackson, Richard, Neil Howe, America . Stanford, CA: Stanford Bucheli, Marisa, Alvaro Forteza, and The and Tobias Peter. 2013. University Press. Ianina Rossi. 2008. Work History Global Aging Preparedness and the Access to Contributory Gill, Indermit, Truman Packard, Index Second edition . Center Pensions in Uruguay: Some Facts Todd Pugatch, and Juan Yermo. for Strategic and International and Policy Options . World Bank 2005. “Rethinking Social Studies, Lanham: Rowman & Social Protection (SP) Discussion Security in Latin America.” Littlefield. Paper 0829, May. International Social Security 58/2-3: 71–96. Review An Aging World: 2015 eau U.S. Census Bur 130

141 James, Estelle, Alejandra Cox _____. 2013a. Pensions at a Glance Social Security _____. 2013b. Edwards, and Augusto Iglesias. . 2013:OECD and G20 Indicators Programs Throughout the 2010. “Chile’s New Pension Paris: OECD Publishing. World: Asia and the Pacific, National Center for Reforms.” . Office of Retirement 2012 _____. 2013b. Pensions at a Glance Policy Analysis Policy Report and Disability Policy. Office Asia/Pacific 2013 . Paris: OECD 326, March. of Research, Evaluation, and Publishing. Statistics. SSA Publication Kinsella, Kevin and Wan He. 13-11802. _____. 2014a. “OECD Income 2009. An Aging World: Distribution Database (IDD): _____. 2014a. Income of the Aged 2008 . U.S. Census Bureau, Gini, Poverty, Income, Methods . Office of Chartbook, 2012 International Population Reports, and Concepts.” Available at Retirement and Disability Policy. P95/09-1. Washington, DC: , accessed on October 1, 13-11727. Institutions, and Welfare 2014. Social Security _____. 2014b. Program Typologies: An Analysis OECD Pensions _____. 2014b. Programs Throughout the World: of Pensions and Old Age Income Outlook 2014 . Paris: OECD . Office of The Americas, 2013 Protection Policies in Sub- Publishing. Retirement and Disability Policy. Poverty & Public Saharan Africa.” Office of Research, Evaluation, 2/1: 37–65. Policy Schultz, T. Paul. 1990. “Women’s and Statistics. SSA Publication Changing Participation in Kritzer, Barbara E. 2008. “Chile’s 13-11804. the Labor Force: A World Next Generation Pension Perspective.” Economic _____. 2014c. Social Security Reform.” Social Security Bulletin Development and Cultural Programs Throughout the 68/2: 69–84. 38/3: 457–488. Change . Office of World: Europe, 2014 Kritzer, Barbara E., Stephen J. Kay, Retirement and Disability Policy. Chile’s Shelton, Alison M. 2012. and Tapen Sinha. 2011. “Next Office of Research, Evaluation, Pension System: Background in Generation of Individual Account and Statistics. SSA Publication . Congressional Research Brief Pension Reforms in Latin 13-11801. Service (CRS) Report for America.” Social Security Bulletin Congress. Stewart, Fiona and Juan Yermo. 71/1: 35–76. OECD 2009. “Pensions in Africa.” Singapore Ministry of Manpower. MacKellar, Landis (ed.). 2009. Working Papers on Insurance 2014. “Singapore Workforce, Pension Systems for the Informal and Private Pensions 30. Paris: 2014: Employment Rate Rose Sector in Asia . Social Protection OECD Publishing. to New High, Sustained Rise in & Labor Discussion Paper 0903. Incomes.” Available at Van Dam, Jaap. 2014. “Towards a Washington, DC: The World , accessed “An Evaluation of Pension on August 25, 2015. Administration in Nigeria.” Social Security Administration. British Journal of Arts and Social Social Security Programs 2013a. Sciences 15/II: 97–108. Throughout the World: Africa, Organisation for Economic 2013 . Office of Retirement Co-operation and Development. and Disability Policy. Office 2012. Pensions at a Glance of Research, Evaluation, and . Paris: OECD Asia/Pacific 2011 Statistics. SSA Publication Publishing. 13-11803. 131 An Aging World: 2015 U.S. Census Bureau

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143 CHAPTER 8. Summary This report has provided an update some African countries already HEALTH AND HEALTH CARE on the world’s older population as have a large number of older The leading causes of death • well as the demographic, health, people. have been shifting in part due and economic aspects of our aging • The oldest segment (aged 80 to increasing longevity, with the world. Among all demographic and over) of the older popula- share due to noncommunicable trends underway in the world today, tion has been growing faster diseases (NCDs) on the rise. it is population aging—and how than the younger segments, NCDs often occur together and societies, families, and individuals thanks to increasing life expec- this multimorbidity increases prepare for and manage it—that tancy at older ages. Some coun- with age. African and other low- may be the most consequential. As tries will experience a quadru- and lower-middle income coun- Suzman said (quoted in Holmes, pling of their oldest population - tries continue to face a consider 2015), “Ageing is reshaping our from 2015 to 2050. able burden from communicable world.” diseases as well. Declining fertility levels have • In addition to updating the most been the main propeller for • People continue to live lon- recent trends, this latest report in population aging and rates ger. Global life expectancy at the Census Bureau’s series of An of decline vary by region and birth reached 68.6 years and is Aging World featured a variety of country. Currently the total fertil- projected to rise to 76.2 years special topics, with some contrib- ity rate is near or below the 2.1 in 2050. Regions and countries uted by researchers outside the replacement level in all regions vary drastically, with current life Census Bureau. Below is a summary except Africa. expectancy exceeding 80 years of select essential points illustrated in 24 countries but less than 60 • Some countries have experi- in this report: years in 28 countries. Among enced simultaneous popula- those reaching older ages, tion aging and population POPULATION GROWTH remaining life expectancy also decline. The traditionally oldest varies notably. In several coun- • In 2015, 8.5 percent of the European countries such as tries, males and females at age world’s population is aged 65 Italy and Spain are no longer 65 can expect to live at least 20 and over. This older population experiencing population decline years and 25 years, respectively, of 617 million is projected to thanks to increases in fertility compared to poorer countries increase by an average of 27 and major immigration flows. where they may live less than 12 million a year over the next 35 New countries joining the list years and 14 years, respectively. years, reaching 1.6 billion in with projected population 2050. The older population is declines between now and 2050 • A portion of one’s expected - expected to represent 16.7 per include some Asian countries years of life may not be healthy cent of the world total popula- driven by rapid fertility decline ones. Healthy life expectancy tion by then. such as China, South Korea, and (HALE) measures the number Thailand. of expected years living in full • While Europe is still the oldest health and without activity region today and is projected to Although the world’s total • limitations. In 2012, HALE for remain so by 2050, aging in Asia dependency ratio in 2050 is women at age 65 in European - and Latin America will acceler projected to remain similar to countries ranged from 3 years ate and rapidly catch up. Asia is the 2015 ratio, the composi- for Slovakians to 16 years for just as notable for leading the tion will change considerably, Norwegians. world in the size of the older with the share due to the older population as speed of aging. At population (rather than children) • A cluster of risk factors are the other end of the spectrum projected to almost double, from directly or indirectly responsible is Africa, exceptionally young in 20 percent to 38 percent in the for the global burden of disease. 2015 in terms of proportion of next 3 decades. For instance, tobacco use has older population, even though dropped in some high-income 133 An Aging World: 2015 U.S. Census Bureau

144 Many workers are uncertain • countries, and the majority of from public pension systems smokers worldwide now live in about their lifestyle after in Organisation for Economic low- and middle-income coun- retirement and many retire Co-operation and Development tries. Increasing obesity, in addi- earlier than they had expected. countries range from under 40 tion to being underweight, has Statutory retirement ages vary percent to over 75 percent. The been associated with increased widely across world regions, yet remainder of income comes mortality at older ages. tend to lump at certain ages, from a mix of other public trans- such as 60 and 65. In several fers, private savings and invest- • The older population has dif- OECD countries, the formal ments, and family support. ferent health care needs than retirement age has risen (or is • Public pensions can drastically younger adults due to increasing set to increase) to well above 65. lower poverty rates for the older chronic diseases and disability The Great Recession (2007– • population. In Latin America at older ages. Provisions for 2009) had a major impact and Caribbean countries, for health care at older ages are on unemployment rates and instance, the average poverty more often available in countries financial assets among many rate of those receiving a pension with social protection systems older people in more developed is 5.3 percent, one-fifth of the or with universal care schemes. countries. However, the trend average poverty rate of those Universal health coverage has of rising labor force participa- not receiving pensions (25.8 become a focus for the post- tion rates among the population percent). 2015 Sustainable Development aged 60 and older in these coun- Goals being set by the United • In addition to reducing poverty, tries was not halted. The Great Nations. public pensions also may reduce Recession had a much smaller • The increasing size and share incentives for private savings, a impact on the majority of less of the older population in any phenomenon known as “crowd- developed countries whose society drives its long-term care ing out.” Debates about the size economies were less linked costs. A wide range of funding and scope of this phenomenon to more developed countries, sources is used for long-term continue. where the recession originated. care, and the care provided Although some of the aforemen- Among mandatory pension pro- • differs in coverage, degree of tioned issues, as well as future grams, earnings-related public cost-sharing, the scope and dynamics of population aging, are PAYGO systems are still the most depth of coverage, and provid- well understood today, the story common. Several countries that ers’ qualifications. of our aging world may evolve in had mandated privatized indi- Older adults are not solely sup- • unexpected ways. The broad institu- vidual retirement accounts have ported by pensions or long-term tional response of governments and either abandoned that approach health insurance. Unpaid care- policymakers to the challenges of entirely (e.g., Argentina) or giving by family members and aging is difficult to anticipate. So too supplemented it with public sys- friends remains the main source are the evolving family institutions tems (e.g., Chile and Ghana). of long-term care for older and social networks that provide the • Pension coverage of the older people worldwide. Informal care foundation of support for each older population varies widely may substitute for formal long- person. As these stories continue throughout the world. More than term care in some circumstances to unfold, societies throughout the 90 percent of the older popula- in Europe, particularly when world will choose common and tion receives a pension in more low levels of unskilled care are diverse ways to respond to these developed countries such as needed. challenges. Japan, United States, Australia, Chapter 8 Reference WORK, RETIREMENT, AND and Italy. In contrast, in the PENSIONS world’s two population billion- Holmes, David. 2015. “Profile: aires, public pensions cover less Labor force participation among • Richard Suzman: Helping than a third of the older popu- the older population contin- the World to Grow Old More lation in China and a tenth of ues to rise in many developed Gracefully.” The Lancet those in India. countries, yet such participation 385/9967: 499. remains far higher in low-income The proportion of income • countries. that older people received An Aging World: 2015 U.S. Census Bureau 134

145 APPENDIX A. Country Composition of World Regions South-Eastern Asia AFRICA Western Africa Brunei Benin Eastern Africa Burkina Faso Burma Burundi Cabo Verde Cambodia Comoros Indonesia Cote d’Ivoire Djibouti Laos Gambia, The Eritrea Ghana Malaysia Ethiopia Guinea Philippines Kenya Singapore Guinea Bissau Madagascar Liberia Thailand Malawi Timor-Leste Mali Mauritius Vietnam Mauritania Mozambique Niger Western Asia Rwanda Nigeria Seychelles Saint Helena Armenia Somalia Senegal Azerbaijan Tanzania Sierra Leone Bahrain Uganda Togo Cyprus Zambia Gaza Strip ASIA Zimbabwe Georgia Middle Africa Iraq Eastern Asia Israel Angola China Jordan Cameroon Hong Kong Kuwait Central African Republic Japan Lebanon Korea, North Chad Oman Congo (Brazzaville) Korea, South Qatar Macau Congo (Kinshasa) Saudi Arabia Equatorial Guinea Mongolia Syria Taiwan Gabon Turkey Sao Tome and Principe United Arab Emirates South-Central Asia West Bank Northern Africa Afghanistan Yemen Bangladesh Algeria EUROPE Egypt Bhutan India Libya Eastern Europe Iran Morocco Kazakhstan South Sudan Belarus Bulgaria Sudan Kyrgyzstan Tunisia Maldives Czech Republic Western Sahara Nepal Hungary Pakistan Moldova Southern Africa Poland Sri Lanka Romania Tajikistan Botswana Russia Turkmenistan Lesotho Uzbekistan Slovakia Namibia Ukraine South Africa Swaziland 135 An Aging World: 2015 U.S. Census Bureau

146 NORTHERN AMERICA Northern Europe LATIN AMERICA AND THE CARIBBEAN Denmark Bermuda Canada Anguilla Estonia Greenland Faroe Island Antigua and Barbuda Finland Saint Pierre and Miquelon Argentina United States Aruba Guernsey Bahamas, The Iceland OCEANIA Barbados Ireland Isle of Man Belize American Samoa Bolivia Jersey Australia Latvia Brazil Cook Islands Lithuania Cayman Islands Fiji Chile Norway French Polynesia Sweden Colombia Guam Costa Rica United Kingdom Kiribati Cuba Marshall Islands Southern Europe Curacao Micronesia, Federated Dominica Albania States of Dominican Republic Andorra Nauru Ecuador Bosnia and Herzegovina New Caledonia El Salvador Croatia New Zealand Grenada Northern Mariana Islands Gibraltar Guatemala Greece Palau Guyana Papua New Guinea Italy Haiti Kosovo Samoa Honduras Macedonia Solomon Islands Jamaica Tonga Malta Mexico Tuvalu Montenegro Montserrat Vanuatu Portugal Nicaragua San Marino Wallis and Futuna Panama Serbia Paraguay Slovenia Peru Spain Puerto Rico Western Europe Saint Barthelemy Saint Kitts and Nevis Austria Saint Lucia Belgium Saint Martin France Saint Vincent and the Germany Grenadines Liechtenstein Sint Maarten Luxembourg Suriname Monaco Trinidad and Tobago Netherlands Turks and Caicos Islands Switzerland Uruguay Venezuela Virgin Islands, British Virgin Islands, U.S. An Aging World: 2015 U.S. Census Bureau 136

147 APPENDIX B. Detailed Tables Table B-1. Total Population, Percentage Older, and Percentage Oldest Old: 1950, 1980, 2015, and 2050 —Con. (Numbers in thousands) 1950 1980 Percent 80 Percent 65 Percent 80 Percent 65 Country Percent 80 and over and over Percent 80 and over and over and over of of total of total and over of Total of total of total Total 65 and over population population population 65 and over population population population Africa Egypt 3.0 0.2 6.7 ... 3.9 0.4 10.3 21,834 43,674 Kenya 6,077 ... 0.3 7.7 16,282 3.0 0.3 10.0 3.9 Malawi 2,881 3.1 6.5 6,215 2.8 0.3 10.7 ... 0.2 Morocco 4.2 0.2 6.9 19,567 ... 0.6 14.3 8,953 2.9 South Africa ... 3.6 0.3 8.3 29,074 3.1 0.4 12.9 13,683 Tunisia 3,530 5.7 0.9 15.8 ... 3.8 0.3 7.9 6,458 Uganda ... 5,158 3.0 0.3 10.0 12,661 2.6 0.2 7.7 Zimbabwe ... 3.2 0.2 6.3 7,285 2.9 0.3 10.3 2,747 Asia Bangladesh 5.1 0.6 11.8 88,855 43,852 0.3 10.3 ... 2.9 China 554,760 4.5 0.3 6.7 998,877 4.7 0.4 8.5 ... India ... 3.1 0.4 12.9 688,575 3.6 0.3 8.3 371,857 Indonesia 79,538 4.0 0.3 7.5 151,108 3.4 0.3 8.8 ... Israel ... 1,258 0.3 7.7 3,764 8.6 1.2 14.0 3.9 Japan 116,807 4.9 0.4 8.2 ... 9.0 1.4 15.6 83,625 Malaysia ... 6,110 5.1 0.6 11.8 13,763 3.7 0.5 13.5 Pakistan 36,944 5.3 0.5 9.4 79,222 3.4 0.4 11.8 ... Philippines ... 19,996 3.6 0.4 11.1 48,088 3.2 0.3 9.4 Singapore ... 10.6 0.5 1,022 2.4 0.4 16.7 2,415 4.7 South Korea ... 3.0 0.2 6.7 38,124 3.8 0.4 10.5 18,859 Sri Lanka 4.4 0.1 2.8 14,941 3.6 0.5 11.4 ... 7,339 Thailand 20,607 3.2 0.4 12.5 46,809 ... 0.5 13.2 3.8 Turkey 4.6 21,484 0.3 9.4 ... 3.2 0.7 15.2 46,316 Europe Austria ... 6,935 10.4 1.2 11.5 7,549 15.4 2.7 17.5 Belgium ... 11.0 1.4 12.7 9,828 14.4 2.6 18.1 8,628 Bulgaria ... 6.7 0.7 10.4 7,251 11.9 1.6 13.4 8,862 Czech Republic ... 8,925 8.3 1.0 12.0 10,284 13.4 1.9 14.2 Denmark 5,123 4,271 9.1 1.2 13.2 ... 14.4 2.9 20.1 France 3.1 ... 41,829 11.4 1.7 14.9 53,880 14.0 22.1 Germany ... 9.7 1.0 10.3 78,289 15.6 2.8 17.9 68,376 Greece 13.1 1.0 14.7 9,643 6.8 2.3 17.6 ... 7,566 Hungary 9,338 7.3 0.8 11.0 10,707 13.4 2.1 15.7 ... Italy ... 8.3 1.1 13.3 56,434 13.1 2.2 16.8 47,104 Norway 3,265 9.7 1.7 17.5 4,086 14.8 3.0 20.3 . . . . . . . . . . . . . . . . . . . Poland ... 24,824 0.7 13.5 35,574 10.1 1.5 14.9 5.2 Russia 138,655 6.2 0.9 14.5 ... 10.2 1.4 13.7 102,702 Sweden ... 7,014 10.3 1.5 14.6 8,310 16.3 3.2 19.6 United Kingdom 50,616 10.7 1.5 14.0 56,314 14.9 2.7 18.1 ... Ukraine ... 37,298 7.6 1.2 15.8 50,044 11.9 1.7 14.3 137 An Aging World: 2015 U.S. Census Bureau

148 Table B-1. Total Population, Percentage Older, and Percentage Oldest Old: 1950, 1980, 2015, and —Con. 2050 (Numbers in thousands) 1950 1980 Percent 80 Percent 65 Percent 80 Percent 65 Country Percent 80 and over and over Percent 80 and over and over and over of of total of total Total and over of of total of total Total 65 and over population population population 65 and over population population population Latin America/Caribbean Argentina 17,150 4.2 0.5 ... 28,094 8.1 1.1 13.6 11.9 Brazil ... 53,975 3.0 0.3 10.0 121,615 4.1 0.5 12.2 Chile 0.9 16.4 5.5 11,174 ... 0.5 4.3 6,082 11.6 Colombia 3.1 0.3 12,568 ... 9.7 28,356 3.8 0.5 13.2 Costa Rica ... 4.8 0.5 10.4 966 4.7 0.8 17.0 2,347 Guatemala ... 3,146 2.5 0.2 8.0 7,013 2.9 0.4 13.8 Jamaica 5.1 1,403 3.9 0.2 ... 2,133 6.7 1.5 22.4 Mexico 17.1 27,741 3.5 0.6 ... 69,325 3.7 0.6 16.2 Peru 8.6 7,632 3.5 0.3 ... 17,325 3.6 0.4 11.1 Uruguay 2,914 16.2 1.7 10.5 17.1 1.4 8.2 2,239 ... Northern America/Oceania Table B-1. Australia 1.1 ... 8,219 8.1 17.7 13.6 14,638 9.6 1.7 Total Population, Percentage Older, and Percentage Oldest Old: 1950, 1980, 2015 and Canada 19.1 7.7 ... 13,737 1.8 1.1 14.3 24,516 9.4 New Zealand 1.1 ... 1,908 9.0 12.2 3,113 10.0 1.7 17.0 2050 —Con. United States 11.2 21.4 ... 157,813 8.3 1.1 13.3 230,917 2.4 (Numbers in thousands) 2050 2015 Percent 80 Percent 65 Percent 80 Percent 65 Country Percent 80 and over and over Percent 80 and over and over and over of of total of total Total and over of of total of total Total 65 and over population population population 65 and over population population population Africa Egypt 5.2 0.7 13.2 137,873 88,487 2.8 21.4 ... 13.1 Kenya 45,925 2.9 0.4 14.3 70,755 9.2 1.5 16.6 ... Malawi ... 0.3 10.8 37,407 4.2 0.6 14.0 17,715 2.7 Morocco 18.6 1.4 21.0 42,026 6.4 4.9 26.4 ... 33,323 South Africa 48,286 6.5 1.0 16.1 49,401 11.4 3.3 28.6 ... Tunisia 20.3 8.0 1.6 ... 11,037 12,180 24.3 6.8 27.9 Uganda 15.6 0.5 3.4 93,476 15.7 0.3 2.0 37,102 ... Zimbabwe 25,198 14,230 3.5 0.7 19.6 6.9 1.2 16.9 ... Asia Bangladesh 5.1 0.7 14.0 250,155 14.6 2.9 20.2 ... 168,958 China 26.8 1.8 18.2 1,303,723 10.1 8.7 32.7 ... 1,361,513 India 1,251,696 6.0 0.8 13.2 1,656,554 14.7 3.2 21.7 ... Indonesia ... 6.6 1.1 16.1 300,183 19.0 4.8 24.9 255,994 Israel ... 10.9 3.0 27.3 10,828 18.1 5.7 31.4 7,935 Japan ... 26.6 8.0 29.9 126,920 40.1 18.3 45.7 107,210 Malaysia 5.6 16.0 4.3 26.8 30,514 0.9 15.4 ... 42,929 Pakistan 4.3 ... 199,086 0.6 14.4 290,848 11.3 2.2 19.5 Philippines 22.9 ... 109,616 4.6 0.7 15.4 171,964 11.7 2.7 Singapore 8.9 2.0 22.9 8,610 23.9 9.1 38.0 ... 5,674 South Korea 21.2 49,115 13.0 2.8 ... 43,369 35.9 14.0 39.1 Sri Lanka 21.2 30.6 6.5 25,167 ... 1.8 9.0 22,053 19.4 Thailand ... 67,976 9.9 1.9 18.9 66,064 27.4 8.7 31.9 Turkey 4.8 6.9 82,523 ... 24.9 19.3 100,955 16.4 1.1 An Aging World: 2015 U.S. Census Bureau 138

149 Table B-1. Total Population, Percentage Older, and Percentage Oldest Old: 1950, 1980, 2015 and —Con. 2050 (Numbers in thousands) 2050 2015 Percent 80 Percent 65 Percent 80 Percent 65 Country Percent 80 and over and over Percent 80 and over and over and over of of total of total and over of Total of total of total Total 65 and over population population 65 and over population population population population Europe Austria 8,224 19.5 5.3 ... 7,521 30.1 12.8 42.4 27.1 Belgium 10,454 5.8 30.1 9,883 27.7 11.1 40.2 ... 19.3 Bulgaria 6,867 19.8 4.7 23.7 4,651 ... 10.7 31.6 33.8 Czech Republic 10,645 18.0 4.1 22.6 ... 29.0 9.0 30.9 10,210 Denmark ... 5,582 18.7 4.3 23.1 5,575 24.6 9.7 39.3 France ... 18.7 5.9 31.4 69,484 25.8 10.3 40.1 66,554 Germany 30.1 5.8 27.2 71,542 21.5 13.3 44.3 ... 80,854 Greece 10,776 20.5 6.2 30.4 ... 32.1 11.6 36.1 10,036 Hungary 9,898 18.2 4.5 ... 8,490 29.9 9.5 31.9 24.6 Italy ... 61,855 6.4 30.4 61,416 31.0 11.9 38.5 21.2 Norway 5,208 16.3 4.2 26.0 6,364 23.0 8.3 36.2 . . . . . . . . . . . . . . . . . . . Poland ... 15.5 4.0 25.8 32,085 31.7 9.9 31.1 38,302 Russia ... 142,424 13.6 3.2 23.7 129,908 25.7 7.7 30.1 Sweden 20.0 5.1 37.1 ... 9,802 8.3 22.3 25.3 12,011 Ukraine ... 16.2 3.5 21.4 33,574 29.3 9.1 31.1 44,009 United Kingdom ... 17.7 4.8 27.2 71,154 23.6 9.1 38.7 64,088 Latin America/Caribbean Argentina 43,432 11.6 3.0 26.1 ... 18.9 5.6 29.3 53,511 Brazil ... 204,260 7.8 1.4 17.8 232,304 21.1 5.8 27.4 Chile ... 10.2 2.1 20.6 19,688 23.2 8.0 34.7 17,508 Colombia 46,737 6.9 1.2 17.6 56,228 19.1 5.9 30.8 ... Costa Rica ... 7.3 1.3 18.4 6,066 20.7 6.2 30.1 4,814 Guatemala ... 14,919 4.3 0.6 14.6 22,995 10.3 2.1 20.4 Jamaica ... 2,950 2.0 25.0 3,555 14.5 3.9 26.6 7.9 Mexico 18.0 1.3 19.7 150,568 6.8 5.1 28.2 ... 121,737 Peru 30,445 7.0 1.2 16.7 ... 17.1 4.5 26.7 36,944 Uruguay 3,342 14.0 3.9 28.0 ... 21.6 7.0 32.3 3,495 Northern America/Oceania Australia ... 22,751 4.1 26.3 29,013 22.5 8.1 36.1 15.5 Canada 35,100 17.7 5.0 28.2 41,136 26.3 10.6 40.5 ... New Zealand ... 14.6 3.7 25.5 5,199 23.0 8.9 38.5 4,438 United States ... 321,369 14.9 3.8 25.3 398,328 22.1 8.2 37.1 . The 2006 Edition ; and U.S. Census Bureau, 2013, Sources: United Nations Department of Economic and Social Affairs, 2007, World Population Prospects 2014a, 2014b; International Data Base, U.S. population estimates, and U.S. population projections. 139 An Aging World: 2015 U.S. Census Bureau

150 Table B-2. Percentage Change in Population for Older Age Groups by Country: 2010 to 2030 and 2030 to 2050 Percent change 2010–2030 Percent change 2030–2050 Country 80 and over 65–79 80 and over 65 and over 65–79 65 and over 55–64 55–64 . . . 2 98 . 2 136 . 2 . . . . . . . . . . . . . . . . . . . 2 89 86 7 106 . 3 157 . 8 114 . 2 Africa 103 151.9 Algeria 148.3 46.1 102.9 197.1 120.1 ... 125.3 133.2 Angola 158.3 100.0 105.3 110.7 144.1 115.0 83.1 ... 93.5 Benin 109.2 117.8 102.3 125.7 176.3 149.4 144.8 ... 188.5 Botswana 47.2 96.3 80.3 81.0 70.7 90.9 75.5 ... 75.8 Burkina Faso 86.0 ... 89.4 101.6 148.5 190.2 153.4 133.4 120.1 Burundi 94.5 139.4 123.6 118.8 194.4 127.7 140.7 ... 130.3 Cameroon 89.8 95.6 116.0 119.1 82.4 122.7 145.0 ... 139.6 Cape Verde 233.3 96.9 87.7 83.5 46.4 107.5 193.0 ... 110.8 Central African Republic 46.6 50.9 47.2 89.5 ... 139.9 103.1 92.4 97.3 Chad 63.7 101.7 67.8 112.4 82.0 116.4 86.4 ... 50.3 Comoros 112.1 148.8 84.1 ... 143.4 137.5 142.5 67.7 75.2 Congo (Brazzaville) ... 116.8 88.6 112.8 51.2 129.0 226.8 141.2 150.2 Congo (Kinshasa) 98.5 92.2 137.5 96.9 125.0 135.4 171.6 139.8 ... Cote d’Ivoire ... 230.6 89.0 89.5 142.7 139.8 142.3 81.1 75.0 Djibouti 102.3 122.8 122.8 138.0 192.4 145.7 113.9 ... 197.3 Egypt 164.4 152.4 73.5 91.1 272.3 103.1 60.9 ... 137.4 Equatorial Guinea 66.7 113.8 72.3 85.3 113.2 169.6 121.4 ... 112.8 Eritrea ... 155.2 71.8 82.1 162.4 135.3 157.4 116.2 59.8 Ethiopia 89.1 175.7 114.4 115.6 ... 170.9 126.3 119.3 107.2 Gabon 38.3 69.8 55.7 66.9 53.1 116.7 51.5 ... 41.4 Gambia, The 107.5 110.7 183.8 119.1 ... 133.7 158.1 137.4 113.8 Ghana 103.9 101.6 104.4 70.5 104.0 167.5 114.2 ... 120.1 Guinea 78.6 164.4 98.8 90.4 96.9 ... 105.6 154.2 90.2 Guinea-Bissau 93.7 148.0 81.2 77.1 74.1 111.9 96.1 ... 59.0 Kenya 112.2 128.2 152.5 131.6 110.4 ... 185.6 159.2 154.5 Lesotho –2.4 35.2 17.4 94.0 57.6 34.8 52.6 ... 13.3 Liberia 73.1 97.5 205.4 107.0 84.1 ... 154.2 122.8 118.1 Libya 230.8 148.1 119.9 143.1 ... 187.0 284.3 202.5 33.6 Madagascar ... 113.3 129.2 116.2 127.3 105.9 115.3 202.7 127.5 Malawi ... 62.4 141.1 80.3 124.7 109.1 117.9 110.3 73.5 Mali ... 85.9 79.2 114.3 105.7 132.3 109.1 78.7 78.3 Mauritania 93.8 111.1 92.0 110.7 165.2 118.6 104.5 ... 160.7 Mauritius 140.6 149.6 11.9 20.7 131.6 43.3 34.1 ... 154.2 Morocco 119.3 101.2 115.8 33.3 70.5 180.4 90.1 ... 100.9 Mozambique ... 86.2 53.4 118.0 89.5 99.5 91.1 54.7 48.4 Namibia 20.7 140.8 61.9 78.8 ... 62.9 48.3 44.5 49.1 Niger 112.3 111.5 98.9 108.0 97.0 138.4 115.9 ... 101.7 Nigeria 79.1 77.0 135.4 82.9 ... 110.4 132.8 113.3 88.1 Rwanda 110.9 152.8 147.3 108.0 144.3 211.5 152.0 ... 112.1 Saint Helena 49.9 118.7 87.4 –36.9 14.9 ... 35.1 93.8 78.6 Sao Tome and Principe 155.8 15.6 61.2 94.0 70.5 238.2 165.8 ... 126.9 Senegal 113.1 112.5 117.6 113.1 108.0 ... 197.7 132.5 122.7 Seychelles 147.4 67.9 117.6 9.7 65.2 222.4 90.6 ... 130.8 Sierra Leone 91.5 49.3 160.1 60.4 74.7 ... 141.0 131.5 129.7 Somalia 154.2 117.8 53.0 110.5 ... 93.9 293.8 110.2 64.2 South Africa ... 1.7 54.6 131.0 66.1 58.8 12.6 71.7 24.9 South Sudan ... 168.6 75.5 155.0 104.0 157.8 296.2 171.6 206.9 Sudan ... 30.7 85.7 81.4 118.8 235.6 133.9 137.2 98.1 Swaziland 26.1 131.8 66.3 111.7 ... 79.8 56.5 51.0 55.9 Tanzania 147.9 161.8 100.3 108.5 91.6 144.1 147.3 ... 105.0 Togo 101.3 116.6 188.0 125.0 ... 124.6 178.0 132.6 110.2 Tunisia 105.8 109.7 115.5 8.3 56.0 173.1 77.2 ... 116.8 Uganda 144.1 90.2 72.8 87.7 ... 136.8 189.6 143.8 149.7 Western Sahara 120.5 139.2 156.5 ... 92.8 108.5 187.7 119.6 141.5 Zambia ... 106.8 88.8 70.7 109.6 136.9 123.6 135.0 68.1 Zimbabwe 44.4 55.0 98.0 62.8 180.3 153.4 81.2 137.4 ... Asia . . . . . . . . . . . . . . . . . . . . 71 . 7 97 . 5 126 . 5 102 . 4 19 . 0 47 . 9 144 . 2 66 . 0 110.4 Afghanistan 93.6 134.5 97.1 84.4 100.0 163.0 106.4 ... Armenia ... 19.9 84.3 44.4 76.3 30.3 1.0 140.9 23.9 Azerbaijan 123.0 100.6 141.7 46.1 ... 44.0 32.6 267.5 62.6 Bahrain 216.1 276.6 93.3 35.4 120.8 ... 148.7 231.8 149.1 An Aging World: 2015 eau U.S. Census Bur 140

151 Table B-2. Percentage Change in Population for Older Age Groups by Country: 2010 to 2030 and 2030 to 2050 —Con. Percent change 2010–2030 Percent change 2030–2050 Country 65 and over 55–64 80 and over 65 and over 65–79 55–64 80 and over 65–79 Asia —Con. Bangladesh ... 61.5 105.3 184.2 117.5 130.3 177.8 113.6 136.5 Bhutan 170.1 77.6 92.6 131.8 134.4 132.4 62.3 ... 81.4 Brunei 247.1 274.6 53.6 73.7 260.7 100.3 ... 96.9 270.4 Burma 117.7 116.6 36.7 75.2 205.7 98.7 92.9 ... 110.0 Cambodia 223.9 135.6 89.1 90.7 125.5 108.2 116.0 ... 137.2 China 105.9 116.1 107.7 –6.2 19.6 168.1 ... 62.1 46.1 Cyprus 97.1 151.8 107.4 26.7 39.4 105.3 54.4 ... 52.1 Gaza Strip 164.0 167.5 139.4 143.8 259.2 161.2 175.9 ... 128.1 Georgia 61.6 35.4 26.8 –3.2 26.9 13.1 6.1 ... 38.4 Hong Kong 131.2 81.3 117.4 –15.5 –11.2 110.3 17.0 ... 21.7 India ... 162.4 105.9 34.1 75.2 162.3 88.8 83.8 98.0 Indonesia 95.3 158.7 107.1 12.6 ... 169.4 83.2 65.6 99.0 Iran 122.6 81.7 118.4 70.6 127.5 203.4 136.0 ... 125.5 Iraq 165.6 154.0 113.8 146.7 72.5 167.2 248.7 180.0 ... Israel ... 75.4 76.2 75.6 25.3 44.6 70.6 51.9 41.8 Japan ... 110.5 33.6 –29.1 6.6 15.3 10.4 –6.8 4.1 Jordan 157.2 101.2 45.4 119.3 170.7 130.8 86.9 ... 174.1 Kazakhstan 160.2 104.5 44.5 33.5 79.9 53.1 49.9 ... 109.7 Korea, North 45.0 180.6 60.3 –4.9 ... 130.7 53.2 93.4 34.1 Korea, South 102.8 182.5 117.0 –20.6 5.6 124.5 33.2 ... 55.7 Kuwait 82.5 352.6 215.2 49.4 198.9 244.4 107.2 ... 96.5 Kyrgyzstan 57.2 122.8 20.3 101.0 64.8 44.7 226.7 67.9 ... Laos ... 101.8 106.2 102.3 90.9 104.9 197.6 116.8 107.7 61.5 66.1 76.8 18.6 47.7 119.1 62.7 Lebanon. . . . . . . . . . . . . . . . . . . . . . . 133.0 Macau 17.7 115.6 199.8 5.3 ... 200.0 54.5 85.7 232.6 Malaysia 91.3 165.8 202.1 171.2 27.8 62.3 201.3 85.2 ... Maldives ... 103.8 116.9 105.9 107.4 120.2 223.7 138.0 128.3 Mongolia ... 158.8 113.8 151.9 50.9 93.0 286.1 118.2 156.3 Nepal ... 91.9 169.8 100.7 90.1 111.8 168.3 120.4 98.2 Oman ... 100.3 94.8 204.2 110.6 139.9 218.3 135.5 201.1 Pakistan 97.0 ... 105.2 115.0 99.4 97.2 100.5 190.0 113.3 Philippines ... 127.5 175.0 134.4 60.6 90.0 175.7 104.5 91.7 Qatar ... 269.6 275.7 35.4 94.5 279.5 111.9 125.0 276.4 Saudi Arabia 150.2 162.7 87.8 140.6 259.1 157.8 161.1 ... 172.6 Singapore 178.8 197.5 65.7 54.9 226.0 86.3 62.2 ... 188.9 Sri Lanka 109.7 151.3 117.6 9.8 ... 112.2 52.3 42.6 35.4 Syria 130.0 125.4 129.3 83.7 129.4 231.8 146.6 ... 137.3 Taiwan 9.6 93.8 114.4 –9.1 121.0 121.8 34.2 ... 37.0 Tajikistan 157.6 141.2 50.9 128.3 87.3 106.8 362.1 131.1 ... Thailand ... 111.3 143.1 116.7 –9.1 24.0 146.1 47.3 63.5 Timor-Leste ... 253.9 131.2 80.3 70.5 185.8 87.0 85.9 118.5 Turkey 65.9 151.7 120.7 23.7 115.3 171.4 83.7 ... 79.3 Turkmenistan 101.9 180.1 79.0 163.3 68.9 65.1 281.7 89.5 ... United Arab Emirates ... 164.2 230.3 171.2 34.1 100.3 225.9 116.4 99.2 Uzbekistan ... 165.1 51.6 139.7 76.0 72.6 254.0 98.3 110.2 Vietnam ... 159.8 65.2 139.3 118.0 66.9 242.2 93.1 39.2 West Bank ... 184.1 148.0 118.1 142.5 85.1 126.5 241.5 145.6 Yemen ... 136.5 96.3 130.2 168.1 158.8 183.8 162.2 96.5 Europe . 10 . 7 37 . 6 48 . 9 40 . 5 –7 . 5 2 . 7 50 . 9 16 1 ... ... 71.3 Albania 126.9 80.7 54.1 2.9 94.0 22.3 23.7 Andorra ... 122.7 66.2 105.4 –53.3 7.1 116.2 34.1 70.8 Austria ... 38.7 48.5 41.4 24.6 –12.7 56.9 7.5 –18.2 Belarus ... 6.4 45.7 22.5 40.0 6.4 6.2 76.0 21.2 Belgium ... 41.2 38.0 40.3 –9.5 –11.3 45.4 5.1 3.8 Bosnia and Herzegovina ... 67.3 122.6 75.5 –15.8 –0.6 117.8 21.7 26.1 Bulgaria ... 5.5 44.8 14.3 –14.6 2.6 19.9 7.5 –23.4 Croatia ... –6.2 34.5 49.9 38.3 –7.3 –3.7 43.7 9.1 Czech Republic ... 33.6 88.1 46.6 –0.1 23.2 25.6 23.9 –9.5 Denmark ... 4.9 31.0 75.1 42.1 –9.2 –6.9 33.7 5.7 Estonia 17.9 –11.1 10.8 39.8 ... –10.8 –5.7 26.3 3.6 Faroe Islands 47.4 14.2 –12.5 5.1 ... 8.8 47.6 59.2 50.8 141 An Aging World: 2015 U.S. Census Bureau

152 Table B-2. Percentage Change in Population for Older Age Groups by Country: 2010 to 2030 and —Con. 2030 to 2050 Percent change 2030–2050 Percent change 2010–2030 Country 80 and over 65 and over 65–79 80 and over 65 and over 55–64 65–79 55–64 —Con. Europe Finland 76.5 49.6 0.7 ... 21.3 –3.0 –21.6 39.7 –14.4 France 49.4 50.7 49.8 –9.8 –3.1 37.6 9.9 ... 5.8 Germany ... 51.6 29.5 –17.5 –22.2 49.3 –1.2 12.0 22.1 Gibraltar –12.0 86.6 30.7 31.7 ... 8.3 25.4 34.2 13.1 Greece 13.0 43.0 26.5 –24.6 20.3 43.3 22.4 ... 24.6 Guernsey 12.2 48.1 55.1 50.2 –6.6 –3.7 ... 11.7 45.9 Hungary –2.1 20.3 29.4 –13.5 13.1 29.0 17.7 ... 58.4 Iceland 20.9 64.5 78.0 9.4 8.1 ... 24.7 70.5 83.5 Ireland 49.3 97.0 79.2 –0.0 73.5 79.3 57.3 ... 50.3 Isle of Man 19.5 49.2 65.3 53.9 –11.8 ... 43.6 11.4 –3.4 Italy 32.7 43.0 30.8 –24.2 7.6 43.8 19.1 ... 25.7 Jersey 8.3 60.1 70.2 62.9 28.7 ... 66.8 5.4 –19.2 Kosovo 74.3 76.6 93.7 79.4 ... 59.2 147.2 74.6 49.4 Latvia ... 4.7 10.8 37.9 16.6 –5.5 –2.2 42.9 9.3 Liechtenstein ... 86.2 133.0 97.4 –7.7 –3.9 64.9 15.5 21.9 Lithuania ... 41.4 33.6 –2.3 2.2 47.4 15.2 18.9 30.7 Luxembourg 8.3 57.2 60.0 14.6 61.1 72.3 25.6 ... 28.9 Macedonia 18.4 54.9 114.0 64.9 2.7 17.6 85.2 32.3 ... Malta ... 55.2 126.6 71.3 10.5 3.9 28.9 11.3 –12.1 Moldova ... 42.9 41.2 42.6 2.6 –9.3 63.6 4.6 –17.4 Monaco ... 57.2 154.5 90.6 4.5 –12.9 48.9 15.4 –36.5 Montenegro ... 20.8 64.6 23.7 51.9 –11.8 21.3 82.5 36.7 Netherlands ... 54.4 88.7 63.2 –7.4 –11.9 47.0 5.6 6.2 . . . . . . . . . . . . . . . . . . . . . . . . 11.1 58.7 57.7 58.4 Norway 14.0 51.9 25.4 22.6 Poland ... 63.7 62.3 63.3 –10.0 11.1 47.8 20.4 1.3 Portugal ... 24.9 24.7 45.6 30.5 –20.4 15.3 38.1 22.3 Romania ... 19.0 52.9 26.2 22.2 29.4 62.2 37.9 –17.8 Russia ... 0.0 52.3 34.0 48.2 9.1 5.3 76.3 19.8 San Marino –24.2 44.5 55.3 66.6 58.6 ... –0.0 62.9 19.6 Serbia –8.9 ... –11.6 22.0 42.0 26.3 10.3 –1.4 46.3 Slovakia ... 65.1 69.3 66.1 –2.0 19.0 61.5 29.5 7.2 Slovenia ... 64.6 46.4 –22.3 –2.4 49.4 11.6 0.2 40.7 Spain 60.8 46.5 –21.9 31.2 68.7 42.1 45.8 ... 48.3 Sweden 23.8 34.5 18.1 7.2 62.7 12.8 8.4 ... 23.6 Switzerland 46.3 60.8 50.4 2.0 7.5 ... 21.6 26.9 54.1 Ukraine 22.6 28.2 23.8 –0.7 0.9 51.4 12.6 ... –5.7 United Kingdom 45.9 53.9 43.6 4.0 1.4 ... 15.0 15.6 39.5 Latin America and the Caribbean . . . . . . . . . . . 70 . 9 104 8 126 . 0 108 . 9 29 . 4 52 . 4 128 . 6 68 . 4 . Anguilla 142.1 202.5 119.4 183.3 16.8 39.0 236.4 74.2 ... Antigua and Barbuda 34.8 95.1 146.5 14.6 161.6 190.3 62.7 ... 85.6 Argentina 27.6 47.7 62.1 51.4 31.9 44.9 57.4 48.3 ... Aruba ... 119.5 204.4 133.1 23.7 9.0 108.3 29.8 25.8 Bahamas, The ... 130.4 182.5 138.8 86.7 40.7 159.8 63.6 5.8 Barbados ... 39.9 131.6 68.6 115.5 –13.9 0.2 133.9 27.0 Belize ... 145.8 111.2 139.5 83.7 98.7 236.4 120.7 128.7 Bolivia ... 106.2 111.3 86.9 96.8 126.8 102.6 73.7 112.6 Brazil 53.6 148.6 119.2 20.9 113.1 137.8 70.1 ... 67.0 Cayman Islands 56.4 191.1 236.3 199.7 21.3 14.9 144.6 42.5 ... Chile ... 111.2 132.2 115.4 16.6 17.9 125.2 41.3 58.3 Colombia ... 148.3 163.0 150.7 28.4 35.8 181.3 61.5 81.7 Costa Rica ... 157.1 174.2 160.2 86.5 49.6 172.5 73.1 34.8 Cuba ... 61.2 60.2 97.5 67.7 –28.4 –2.3 102.2 22.6 Curacao ... 78.6 131.2 89.1 29.9 –21.7 59.7 –1.8 –11.4 Dominica ... 69.2 41.5 62.2 6.5 25.2 137.2 50.0 64.7 Dominican Republic ... 117.5 153.2 124.1 84.7 49.6 146.0 69.5 35.3 Ecuador ... 78.1 116.4 126.1 118.5 50.5 64.4 129.3 78.6 El Salvador ... 79.0 104.0 83.8 66.1 62.9 119.3 75.0 45.6 Grenada ... 53.2 91.0 108.6 93.9 32.3 12.6 123.5 32.2 Guatemala 120.6 63.1 113.6 159.5 ... 130.5 100.0 135.9 106.4 Guyana 57.8 123.8 170.6 37.0 41.2 ... 53.6 129.6 96.8 An Aging World: 2015 eau U.S. Census Bur 142

153 Table B-2. Percentage Change in Population for Older Age Groups by Country: 2010 to 2030 and 2030 to 2050 —Con. Percent change 2010–2030 Percent change 2030–2050 Country 65 and over 65–79 80 and over 65 and over 55–64 65–79 55–64 80 and over Latin America and the Caribbean —Con. Haiti 149.2 78.1 82.6 97.9 132.7 105.5 71.1 71.2 ... Honduras ... 163.8 136.9 85.0 105.2 181.3 118.9 115.8 131.7 Jamaica 37.8 57.2 42.5 80.5 68.8 68.4 68.7 ... 55.5 Mexico 64.0 138.0 114.7 28.5 109.4 147.5 81.3 ... 98.1 Montserrat 183.7 98.2 2.6 76.8 –6.6 107.8 286.3 131.0 ... Nicaragua ... 136.1 126.5 78.2 98.5 185.7 113.9 118.4 124.5 Panama 84.9 148.2 113.1 25.6 ... 125.6 73.4 57.8 104.5 Paraguay 65.3 127.6 130.0 63.9 130.6 147.6 81.9 ... 90.3 Peru 73.2 95.0 158.4 104.6 39.6 54.8 139.4 70.9 ... Puerto Rico ... 97.8 49.8 –0.6 34.7 30.8 10.0 –1.5 0.4 Saint Barthelemy 3.0 107.4 267.4 133.5 –26.0 –21.0 67.6 1.7 ... Saint Kitts and Nevis ... 95.2 190.2 46.5 150.7 8.9 30.4 210.0 59.2 Saint Lucia ... 140.7 84.0 122.5 –0.0 44.7 161.5 75.7 98.5 Saint Martin 19.5 207.0 139.9 12.7 124.3 82.6 34.7 ... 23.5 Saint Vincent and the Grenadines 67.3 111.6 60.2 100.0 –1.8 21.1 153.3 45.0 ... Sint Maarten ... 446.1 595.6 462.9 –4.0 –20.9 280.0 20.9 67.8 Suriname ... 125.0 93.8 119.6 140.3 77.0 243.1 102.1 22.1 Trinidad and Tobago ... 19.0 118.7 129.3 120.6 3.3 12.7 115.8 31.8 Turks and Caicos Islands . . . . . . . . . . 265.9 144.7 238.4 22.0 189.1 330.8 212.3 351.3 Uruguay ... 29.8 34.1 30.9 20.8 19.3 51.8 28.1 20.5 Venezuela ... 76.4 148.0 129.0 144.5 42.2 56.6 151.8 73.3 Virgin Islands, British 100.9 243.9 206.8 236.4 38.9 49.9 197.9 76.9 ... Virgin Islands, U.S ... 0.7 50.5 220.5 80.1 –33.2 –15.7 35.5 0.2 2 Northern America . . . . . . . . . 7 . 7 81 . 3 68 . 5 77 . 7 16 . 9 2 . 6 68 . 7 20 . ... 90.3 –5.3 Bermuda 66.9 –1.4 –31.1 114.8 96.2 –4.3 Canada ... 84.0 81.7 83.3 12.2 –5.2 57.0 12.9 5.8 Greenland –37.8 179.9 130.5 4.5 123.2 168.4 –5.8 ... 14.1 Saint Pierre and Miquelon 16.5 42.6 83.2 53.3 ... –11.5 48.2 7.3 –57.9 United States 5.6 82.7 72.2 ... 19.6 –1.0 59.0 15.1 79.8 Oceania . . . . . . . . . . . . . . . . . 32 . 4 77 . 5 87 . 1 80 . 0 20 . 2 23 . 9 65 . 3 35 . 4 American Samoa ... 198.7 163.1 193.5 26.8 31.2 301.1 66.9 85.5 Australia ... 70.3 82.0 73.6 14.9 15.6 54.3 27.1 21.2 Cook Islands 8.5 21.7 77.0 30.1 –36.7 –22.8 97.3 1.8 ... Fiji 49.2 125.9 280.0 141.1 33.8 49.7 164.8 67.5 French Polynesia ... 141.9 241.6 156.3 90.6 42.3 172.0 67.3 20.8 Guam ... 41.2 117.9 189.5 130.4 19.6 15.8 123.9 39.6 Kiribati 123.5 ... 81.8 120.4 146.2 71.3 75.7 229.0 92.1 Marshall Islands ... 209.4 183.8 205.4 71.7 113.6 216.6 128.9 85.7 Micronesia, Federated States of ... 57.8 105.5 18.9 34.6 131.7 44.4 29.9 112.7 Nauru 98.4 213.3 326.5 67.1 339.4 444.7 124.4 ... 64.0 New Caledonia 87.2 92.4 206.7 110.8 ... 66.5 124.5 80.1 24.1 New Zealand 27.0 78.3 77.5 4.9 4.2 68.9 22.2 ... 77.2 Northern Mariana Islands ... 457.2 394.3 449.3 48.6 59.1 403.2 98.1 114.1 Palau ... 65.3 181.9 108.0 160.2 –3.1 –4.7 202.1 43.9 Papua New Guinea ... 125.7 222.7 136.6 49.6 98.2 182.4 111.0 104.7 Samoa ... 95.6 96.0 95.6 52.8 52.1 171.8 72.7 90.1 Solomon Islands 155.8 111.0 169.1 120.3 70.7 147.1 180.6 153.6 ... Tonga ... 31.7 79.7 40.0 4.1 56.6 133.5 73.7 73.5 Tuvalu ... –6.1 107.7 51.7 98.9 118.2 –5.5 160.0 14.3 Vanuatu 167.6 119.4 158.6 232.8 ... 72.5 104.2 250.8 126.2 Wallis and Futuna 97.8 62.5 51.1 ... 42.5 99.6 171.8 113.4 31.0 Source: U.S. Census Bureau, 2013; International Data Base. 143 An Aging World: 2015 U.S. Census Bureau

154 Table B-3. Median Age: 2015, 2030, and 2050 (In years) 2015 2030 Country 2050 Africa Algeria 27.5 31.8 ... 37.0 Angola 22.6 19.5 18.0 ... Benin 17.9 20.8 26.1 ... Botswana 29.0 25.6 ... 23.1 Burkina Faso 18.6 21.7 ... 17.1 Burundi 20.4 17.0 ... 17.9 Cameroon 31.3 ... 24.5 38.6 Cape Verde 20.4 24.3 ... 18.4 Central African Republic 19.5 21.3 ... 24.8 Chad 17.4 24.8 ... 20.9 Comoros 25.1 33.4 ... 19.4 Congo (Brazzaville) ... 23.5 19.8 20.7 Congo (Kinshasa) 18.1 22.1 ... 28.8 Cote d’Ivoire ... 20.5 24.5 30.4 Djibouti 23.2 ... 28.0 33.3 Egypt 25.3 28.8 ... 34.1 Equatorial Guinea 22.6 28.4 19.5 ... Eritrea ... 19.3 23.7 30.1 Ethiopia 19.8 17.7 ... 24.3 Gabon 18.6 21.6 ... 19.4 Gambia, The 24.9 31.8 ... 20.5 Ghana 20.9 22.8 26.0 ... Guinea ... 23.8 18.8 20.3 Guinea-Bissau 19.9 26.7 ... 22.3 Kenya 25.2 33.9 ... 19.3 Lesotho 23.8 26.5 32.5 ... Liberia ... 21.6 26.8 18.1 Libya 28.0 34.2 40.2 ... Madagascar ... 19.4 22.6 28.8 Malawi ... 17.5 19.4 23.7 Mali ... 18.2 23.7 16.1 Mauritania ... 28.5 20.1 23.2 Mauritius 34.4 39.3 ... 44.4 Morocco 28.5 39.4 ... 34.0 Mozambique 18.5 21.6 ... 17.0 Namibia 23.1 34.1 ... 28.5 Niger ... 17.7 23.0 15.2 Nigeria 18.2 20.0 ... 23.1 Rwanda 18.8 21.7 ... 24.3 Saint Helena 41.0 49.6 ... 46.7 Sao Tome and Principe 23.0 31.1 ... 17.9 Senegal ... 21.6 26.8 18.5 Seychelles 34.4 41.5 49.2 ... Sierra Leone 19.0 20.0 22.2 ... Somalia ... 17.8 19.5 23.2 South Africa ... 29.3 33.4 25.9 South Sudan ... 26.7 17.0 20.7 Sudan ... 24.6 31.5 19.3 Swaziland 21.2 25.0 29.6 ... Tanzania ... 19.8 23.5 17.5 Togo ... 21.4 25.1 19.6 Tunisia 31.9 38.8 44.0 ... Uganda ... 15.6 17.4 21.9 Western Sahara ... 23.9 28.8 20.9 Zambia ... 17.6 19.8 16.7 Zimbabwe 20.5 22.0 25.9 ... Asia Afghanistan ... 20.7 25.6 18.4 Armenia ... 34.2 42.4 51.3 Azerbaijan ... 30.5 37.4 42.3 Bahrain 36.9 ... 31.8 34.1 Bangladesh 30.8 24.7 ... 37.7 An Aging World: 2015 eau U.S. Census Bur 144

155 Table B-3. Median Age: 2015, 2030, and 2050 —Con. (In years) Country 2050 2015 2030 Asia —Con. Bhutan 41.7 26.7 33.6 ... Brunei ... 33.9 38.1 29.6 Burma 33.4 ... 28.3 38.0 Cambodia 29.3 35.2 ... 24.5 China ... 42.9 48.9 37.0 Cyprus 36.1 41.8 48.7 ... Gaza Strip ... 23.9 32.9 18.4 Georgia ... 45.1 37.9 41.8 Hong Kong ... 49.5 54.1 43.6 India 27.3 31.8 37.2 ... Indonesia ... 34.4 40.9 29.6 Iran ... 36.9 42.5 28.8 Iraq 21.8 26.5 33.2 ... Israel ... 30.1 32.9 38.2 Japan ... 52.6 56.4 46.5 Jordan ... 30.7 23.0 26.0 Kazakhstan ... 34.9 38.4 30.0 Korea, North 33.6 37.3 41.8 ... Korea, South ... 48.3 55.1 40.8 Kuwait ... 31.0 33.9 29.0 Kyrgyzstan 26.0 29.3 34.5 ... Laos ... 22.3 27.8 34.2 Lebanon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.9 46.8 39.2 Macau ... 46.2 55.0 38.2 Malaysia 27.9 31.9 36.7 ... Maldives ... 27.4 35.0 42.3 Mongolia 27.5 33.7 39.2 ... Nepal ... 23.4 30.3 36.6 Oman ... 25.1 28.4 33.2 Pakistan ... 23.0 29.0 35.9 Philippines ... 27.4 32.5 23.7 Qatar ... 35.2 32.8 34.8 Saudi Arabia 26.8 31.9 ... 36.5 Singapore 34.0 47.0 ... 39.2 Sri Lanka 36.5 41.3 ... 32.1 Syria 23.5 36.9 ... 29.5 Taiwan ... 47.5 54.9 39.7 Tajikistan 23.9 28.2 34.4 ... Thailand ... 42.8 48.5 36.7 Timor-Leste ... 28.6 18.6 21.7 Turkey ... 35.2 41.4 30.0 Turkmenistan 27.1 33.3 38.1 ... United Arab Emirates ... 30.3 30.8 30.3 Uzbekistan ... 35.1 42.3 27.6 Vietnam 29.6 36.6 43.3 ... West Bank ... 22.7 28.6 36.0 Yemen ... 24.2 32.0 18.9 Europe Albania 39.4 49.8 ... 32.0 Andorra ... 52.2 54.2 43.0 Austria 44.6 47.6 49.6 ... Belarus ... 44.8 48.3 39.6 Belgium ... 43.3 47.2 45.5 Bosnia and Herzegovina ... 41.2 47.2 53.0 Bulgaria ... 42.8 53.0 48.4 Croatia ... 46.4 49.7 42.3 Czech Republic 41.3 46.6 47.8 ... Denmark ... 41.8 42.4 45.0 Estonia 41.5 46.3 51.7 ... Faroe Islands ... 37.7 38.0 40.1 Finland ... 43.3 45.3 46.8 France ... 41.1 44.0 42.8 145 An Aging World: 2015 U.S. Census Bureau

156 Table B-3. Median Age: 2015, 2030, and 2050 —Con. (In years) 2015 2030 Country 2050 —Con. Europe Germany ... 49.1 46.5 48.5 Gibraltar 43.0 34.2 ... 38.6 Greece 50.3 ... 43.8 48.8 Guernsey 45.8 43.4 ... 47.6 Hungary 46.7 49.5 41.4 ... Iceland ... 36.6 40.4 44.1 Ireland 40.1 ... 36.1 42.1 Isle of Man 43.7 45.4 ... 47.0 Italy 49.0 49.4 44.8 ... Jersey ... 39.0 40.1 44.3 Kosovo 34.1 28.2 ... 41.1 Latvia 41.7 52.3 ... 46.4 Liechtenstein 44.8 45.9 ... 42.7 Lithuania 41.5 46.6 53.4 ... Luxembourg ... 41.4 39.6 39.9 Macedonia 37.2 42.5 ... 47.6 Malta 41.2 50.3 ... 46.2 Moldova 42.5 47.5 ... 36.0 Monaco ... 71.7 51.7 63.4 Montenegro 39.7 46.9 ... 50.8 Netherlands ... 42.3 43.2 44.4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.1 41.1 43.6 Norway Poland ... 51.9 39.9 46.6 Portugal 41.5 49.4 ... 46.6 Romania 46.6 51.5 ... 40.2 Russia 39.1 44.0 45.7 ... San Marino ... 46.7 48.6 43.9 Serbia 42.1 46.1 49.6 ... Slovakia ... 39.2 50.1 45.7 Slovenia ... 43.8 52.7 49.4 Spain ... 49.2 42.0 47.2 Sweden 41.2 41.5 ... 42.1 Switzerland 42.1 45.0 ... 44.1 Ukraine 45.8 50.4 ... 40.8 United Kingdom 40.4 43.3 ... 41.9 Latin America and the Caribbean Anguilla ... 38.6 41.6 34.3 Antigua and Barbuda 31.4 35.4 40.4 ... Argentina ... 34.9 39.7 31.4 Aruba ... 44.5 39.0 42.1 Bahamas, The ... 36.1 41.0 31.5 Barbados 38.0 42.8 46.1 ... Belize ... 26.7 32.8 22.1 Bolivia ... 23.7 35.1 28.6 Brazil ... 31.1 36.9 43.4 Cayman Islands ... 39.7 43.8 41.7 Chile ... 44.5 33.7 39.2 Colombia ... 35.1 41.6 29.3 Costa Rica 30.4 36.7 42.4 ... Cuba ... 44.3 49.2 40.4 Curacao ... 39.3 43.3 36.1 Dominica 32.6 40.1 50.1 ... Dominican Republic ... 27.4 32.6 38.4 Ecuador ... 32.6 39.7 27.0 El Salvador ... 34.1 44.3 26.1 Grenada 30.4 38.1 42.9 ... Guatemala ... 21.4 26.8 34.0 Guyana 25.4 31.9 40.2 ... Haiti ... 22.5 28.1 34.6 Honduras ... 22.3 27.8 34.5 Jamaica 38.2 ... 25.3 30.9 Mexico ... 39.3 32.7 27.6 An Aging World: 2015 eau U.S. Census Bur 146

157 Table B-3. Median Age: 2015, 2030, and 2050 —Con. (In years) 2015 2030 Country 2050 —Con. Latin America and the Caribbean Montserrat ... 38.3 49.7 31.9 Nicaragua 32.4 41.6 24.7 ... Panama ... 28.6 33.1 39.3 Paraguay 27.3 34.4 42.0 ... Peru ... 39.5 27.3 33.0 Puerto Rico ... 44.3 51.1 39.1 Saint Barthelemy 43.0 48.4 47.7 ... Saint Kitts and Nevis ... 41.2 48.5 34.0 Saint Lucia 33.5 43.8 55.8 ... Saint Martin ... 32.0 34.9 36.4 Saint Vincent and the Grenadines ... 40.3 46.6 32.5 Sint Maarten ... 41.3 44.8 40.4 Suriname 29.1 34.6 41.7 ... Trinidad and Tobago ... 44.0 47.7 35.0 Turks and Caicos Islands 32.4 38.1 42.3 . . . . . . . . . . . . . . . . Uruguay ... 34.5 38.1 43.7 Venezuela ... 32.0 37.0 27.2 Virgin Islands, British 35.9 39.7 41.9 ... Virgin Islands, U.S. ... 44.9 53.7 59.4 Northern America Bermuda ... 43.1 44.3 45.6 Canada 45.4 ... 41.8 44.3 Greenland ... 36.9 40.6 33.7 Saint Pierre and Miquelon ... 54.3 57.8 45.2 United States ... 39.6 40.6 37.7 Oceania American Samoa 28.8 38.0 46.9 ... Australia ... 40.7 42.7 38.4 Cook Islands 35.2 42.3 46.4 ... Fiji ... 28.2 33.4 39.3 French Polynesia ... 37.8 44.2 31.0 Guam 30.1 34.3 39.9 ... Kiribati ... 23.9 29.5 35.1 Marshall Islands ... 22.6 27.7 36.0 Micronesia, Federated States of ... 24.2 30.5 37.3 Nauru ... 25.7 33.2 29.3 New Caledonia ... 36.2 41.8 31.4 New Zealand 37.7 40.1 42.9 ... Northern Mariana Islands ... 40.5 48.8 32.1 Palau 33.2 36.5 41.2 ... Papua New Guinea ... 22.6 27.0 32.6 Samoa ... 29.7 36.8 23.5 Solomon Islands 21.9 26.9 33.9 ... Tonga ... 22.3 28.6 43.6 Tuvalu 25.2 28.8 32.2 ... Vanuatu ... 21.4 26.8 34.3 Wallis and Futuna 48.4 39.8 30.9 ... Source: U.S. Census Bureau, 2013; International Data Base. 147 An Aging World: 2015 U.S. Census Bureau

158 Table B-4. Sex Ratio for Population 35 Years and Over by Age: 2015, 2030, and 2050 (Men per 100 women) 2015 2030 2050 Country 80 and 80 and 50–64 65–79 80+ 35–49 50–64 65–79 65–79 over 35–49 35–49 50–64 over Africa Algeria 102.5 102.8 100.8 95.5 72.6 102.3 101.9 93.0 72.7 104.1 73.8 ... 89.4 Angola 99.5 102.6 98.4 86.2 72.5 101.6 75.2 90.7 67.5 101.9 ... 87.5 94.4 Benin 65.7 103.2 102.0 100.1 76.0 53.1 101.9 98.9 91.4 66.3 ... 81.6 66.0 Botswana 90.9 56.3 135.7 142.8 77.4 51.1 149.3 132.0 128.4 71.5 155.1 ... 69.5 Burkina Faso 98.5 58.9 101.2 99.1 74.6 44.5 60.6 95.3 86.0 59.0 105.0 ... 83.7 Burundi 90.8 76.0 61.3 ... 97.0 83.8 63.9 97.9 94.3 88.3 67.0 100.0 98.2 Cameroon 96.2 88.8 75.9 100.9 98.6 88.1 72.0 98.7 97.0 90.0 67.7 ... 101.5 Cape Verde 91.5 54.9 95.5 89.6 74.6 48.1 95.4 93.2 83.0 56.3 80.9 ... 62.7 Central African Republic 99.8 59.7 101.3 94.9 80.1 50.5 65.1 97.0 85.6 62.7 99.6 ... 88.7 Chad 80.7 71.9 62.8 89.1 74.2 72.3 ... 96.1 88.0 68.9 53.2 78.8 57.3 Comoros 82.6 87.6 90.3 89.1 88.9 77.2 68.8 91.1 86.8 79.5 62.5 ... 91.3 Congo (Brazzaville) 67.6 80.9 60.2 93.3 107.7 96.7 103.7 99.9 93.1 89.6 79.1 ... 110.7 Congo (Kinshasa) 99.6 92.0 99.4 57.1 99.5 94.7 81.1 57.9 ... 95.5 83.9 61.1 75.1 Cote d’Ivoire 107.6 102.9 88.8 103.4 102.7 89.4 70.0 103.0 99.9 89.2 65.7 ... 93.6 Djibouti 67.3 63.3 71.6 63.4 68.8 60.8 82.2 70.0 56.2 40.5 81.3 ... 84.1 Egypt 103.1 56.9 105.0 98.5 83.4 54.3 86.7 101.0 92.1 51.7 101.8 ... 96.7 Equatorial Guinea 78.8 72.2 73.5 102.1 96.3 72.0 ... 101.8 99.5 89.2 61.3 99.5 56.0 Eritrea 82.1 74.9 75.9 98.1 94.6 74.4 55.5 99.5 94.9 83.6 62.0 ... 99.1 Ethiopia 61.6 84.2 66.5 96.6 94.5 82.8 95.8 97.0 92.1 82.2 58.2 ... 99.4 Gabon 98.0 95.7 79.9 52.9 110.3 86.3 77.5 ... 112.5 103.1 76.9 48.9 56.4 Gambia, The 96.4 93.2 76.4 96.2 93.3 82.0 64.7 98.5 93.3 82.1 57.2 ... 89.5 Ghana 93.2 87.6 79.5 93.6 90.4 86.8 67.9 ... 89.9 80.6 62.1 94.8 96.0 Guinea 63.8 81.5 63.9 101.3 96.2 84.3 93.3 100.7 97.6 88.6 64.2 ... 100.3 Guinea-Bissau ... 70.9 60.5 58.4 98.6 93.8 62.6 42.3 98.5 92.1 79.0 54.2 101.6 Kenya 99.8 106.0 72.2 101.4 103.2 79.2 59.9 77.6 99.5 92.2 64.8 ... 87.9 Lesotho ... 113.0 109.9 81.1 95.8 127.2 113.3 90.7 97.7 116.3 121.1 96.5 105.3 Liberia ... 100.5 94.4 97.9 87.7 96.4 95.8 82.3 72.5 99.7 91.5 84.9 59.6 Libya ... 110.1 104.1 87.3 111.2 108.2 92.4 77.1 103.6 105.6 102.0 69.8 101.2 Madagascar ... 83.3 80.0 99.1 97.7 91.3 70.4 99.0 96.5 90.4 71.9 99.6 96.1 Malawi 107.7 63.3 103.7 103.0 74.9 55.9 103.2 100.1 89.8 59.3 87.0 ... 74.5 Mali 89.8 89.8 84.3 93.7 95.3 81.8 101.6 84.9 81.7 70.1 90.5 ... 100.2 Mauritania 83.6 75.3 63.4 87.3 80.9 75.8 ... 91.0 85.4 73.4 54.5 84.1 58.9 Mauritius 92.3 74.0 47.4 100.7 94.7 78.9 49.8 102.6 97.2 84.0 53.6 ... 99.5 Morocco 59.6 86.7 65.8 94.7 90.6 88.2 97.0 97.0 93.2 83.3 57.5 ... 92.2 Mozambique 90.2 92.5 86.7 75.1 89.5 89.8 ... 70.0 100.3 92.4 78.2 60.6 86.3 Namibia 116.8 84.9 65.3 121.9 114.1 68.8 52.7 127.3 133.4 108.8 49.9 ... 77.3 Niger 102.8 104.4 99.0 100.4 106.3 106.4 93.3 ... 99.2 99.3 84.9 97.8 106.8 Nigeria 74.5 92.1 82.7 104.8 102.7 88.6 97.6 102.6 101.3 92.4 71.0 ... 107.0 Rwanda ... 93.6 71.4 60.5 97.8 99.1 85.8 59.5 98.7 94.6 87.7 69.8 102.1 Saint Helena 103.4 98.4 54.6 99.9 95.7 92.5 83.5 122.6 99.1 87.2 60.7 ... 103.8 Sao Tome and Principe ... 87.2 82.1 78.5 96.9 94.8 79.8 62.9 99.6 95.8 86.9 66.1 94.9 Senegal ... 79.7 76.9 82.9 76.5 87.4 76.4 69.7 64.5 92.5 86.3 71.0 51.6 Seychelles ... 105.2 76.1 33.0 124.7 110.2 88.0 41.2 135.6 127.0 100.9 52.1 112.3 Sierra Leone ... 72.7 77.3 91.1 87.3 78.4 53.8 95.2 87.2 77.3 56.7 91.9 87.8 Somalia 48.3 64.0 61.8 102.9 108.6 93.4 101.1 95.2 97.2 89.1 76.5 ... 112.5 South Africa 112.7 78.4 68.1 52.8 125.7 106.8 ... 46.4 119.8 123.2 106.3 46.8 64.6 South Sudan 102.6 88.2 118.9 100.7 85.9 100.5 97.5 127.7 103.9 75.3 67.0 ... 112.2 Sudan ... 107.6 119.7 118.2 97.8 85.8 97.2 93.7 98.5 97.7 75.9 66.9 90.1 Swaziland ... 112.1 71.3 64.8 61.4 120.1 109.7 58.3 44.0 120.0 122.6 108.6 46.4 Tanzania ... 84.1 75.8 68.8 99.2 99.7 76.3 60.9 100.5 96.3 88.1 66.2 102.9 Togo ... 91.2 79.2 58.3 98.5 95.1 79.0 55.1 98.5 95.0 84.1 54.7 99.6 Tunisia ... 101.8 99.3 86.5 89.3 97.3 94.1 79.0 85.5 91.2 91.1 73.0 100.4 Uganda 65.2 ... 79.4 74.7 100.7 98.2 86.5 95.4 97.6 96.4 87.9 68.1 101.0 Western Sahara ... 95.8 89.4 80.1 68.2 97.5 91.8 81.0 63.8 98.4 94.1 83.0 60.9 Zambia 99.2 104.1 91.7 78.3 64.7 99.7 ... 76.9 63.1 99.2 95.1 84.9 60.3 Zimbabwe 106.2 114.4 43.5 55.4 101.0 ... 133.0 65.7 62.0 72.3 108.0 125.0 56.1 An Aging World: 2015 eau U.S. Census Bur 148

159 Table B-4. Sex Ratio for Population 35 Years and Over by Age: 2015, 2030, and 2050 —Con. (Men per 100 women) 2015 2030 2050 Country 80 and 80 and 50–64 65–79 80+ 35–49 50–64 65–79 over over 50–64 35–49 65–79 35–49 Asia Afghanistan 98.8 102.5 98.7 87.3 67.9 104.2 97.0 86.6 65.0 100.6 73.5 ... 87.7 Armenia 112.7 102.5 98.5 78.2 53.9 102.5 57.2 101.4 60.8 92.0 ... 69.6 84.0 Azerbaijan 66.3 85.8 102.4 87.8 71.8 43.7 113.5 100.7 80.6 47.8 ... 92.7 48.0 Bahrain 180.8 80.8 175.6 164.3 105.9 72.7 177.3 200.8 113.0 73.2 142.6 ... 98.5 Bangladesh 99.9 76.8 101.2 99.6 90.9 76.6 100.3 101.6 94.9 62.7 93.1 ... 99.7 Bhutan 115.4 111.7 101.5 ... 118.7 108.4 92.7 103.2 101.4 108.3 86.4 120.2 106.3 Brunei 102.7 100.7 66.5 86.4 81.2 90.0 73.0 88.5 78.5 70.3 56.8 ... 92.9 Burma 99.0 62.4 99.3 94.5 79.9 58.5 100.3 95.6 84.1 58.0 90.7 ... 79.7 Cambodia 98.0 51.4 95.8 91.3 69.2 48.7 61.8 91.8 83.3 59.1 95.0 ... 74.8 China 102.5 96.8 72.8 106.4 101.0 91.3 ... 112.5 106.2 90.7 64.7 104.1 68.7 Cyprus 93.0 82.3 55.5 114.5 103.4 82.9 57.1 115.4 111.6 96.9 58.9 ... 108.9 Gaza Strip 57.7 74.0 58.3 103.8 102.7 96.6 105.5 104.4 101.9 93.0 72.1 ... 105.0 Georgia 94.4 81.9 71.4 50.0 98.8 87.8 70.2 48.4 108.6 98.6 78.1 48.7 ... Hong Kong ... 90.5 100.5 65.9 82.5 67.0 82.4 71.4 94.7 88.3 64.1 49.9 68.6 India ... 92.8 74.2 108.9 101.3 91.2 71.8 112.0 107.3 92.6 68.5 105.1 101.6 Indonesia 106.1 61.4 105.0 102.1 78.1 55.9 105.8 102.0 90.4 59.8 88.1 ... 80.2 Iran 104.2 78.1 104.6 101.5 87.8 64.6 87.8 102.3 92.7 65.7 104.1 ... 97.1 Iraq 97.2 88.5 78.5 102.2 103.0 90.5 ... 102.3 99.8 93.1 74.9 105.5 73.9 Israel 98.2 86.2 63.1 103.8 102.5 90.5 65.7 103.5 101.7 94.3 68.6 ... 104.6 Japan 61.8 89.2 54.1 99.0 95.6 92.3 100.6 106.1 103.7 88.9 63.8 ... 97.5 Jordan 100.8 96.5 93.2 85.3 94.0 95.6 ... 71.3 96.7 90.7 84.7 71.4 90.3 Kazakhstan 93.8 80.1 26.7 97.7 85.5 63.4 30.2 95.6 92.3 73.1 37.4 ... 59.2 Korea, North 99.7 60.2 17.0 101.4 95.1 72.5 ... 100.8 97.0 79.0 43.4 29.5 92.6 Korea, South 57.7 79.9 45.5 111.5 98.9 87.9 98.1 106.9 109.1 93.3 64.8 ... 102.2 Kuwait 176.0 ... 91.5 74.3 162.5 127.7 72.4 54.6 152.7 117.5 68.8 45.9 144.7 Kyrgyzstan ... 80.0 66.3 48.3 95.9 84.0 65.1 45.0 99.6 89.1 73.1 44.5 94.7 Laos ... 95.7 84.7 70.5 98.3 93.0 96.3 64.4 99.0 94.2 85.0 60.0 85.6 Lebanon. . . . . . . . . . . . . . . . . . . . . . 90.8 85.2 86.5 71.2 95.8 90.0 79.5 64.3 93.0 94.4 85.8 59.3 Macau ... 82.4 100.5 93.9 73.9 79.3 81.4 92.2 70.9 93.9 91.2 65.2 63.8 Malaysia ... 104.3 95.8 64.8 101.0 101.4 92.8 67.6 102.6 98.8 89.6 64.1 103.5 Maldives ... 88.3 90.8 101.8 92.7 77.1 63.0 102.9 99.4 88.0 57.5 131.9 105.4 Mongolia 93.5 50.3 92.7 85.2 69.6 46.0 95.8 87.7 71.3 45.6 86.7 ... 73.7 Nepal 99.6 79.2 102.2 97.8 88.1 67.3 86.6 100.4 91.6 66.0 92.2 ... 95.2 Oman 126.8 100.2 93.2 125.9 113.8 87.4 ... 124.1 106.5 94.0 66.5 147.4 73.5 Pakistan 102.9 89.4 77.0 106.6 105.0 93.0 66.5 104.4 102.5 94.2 68.5 ... 108.7 Philippines 56.4 79.3 58.1 102.9 97.4 78.5 88.7 103.9 100.1 88.7 57.7 ... 101.5 Qatar 578.8 387.7 185.2 79.6 546.3 532.8 ... 89.8 472.9 416.3 232.0 88.5 197.3 Saudi Arabia 136.7 125.5 96.6 122.4 113.0 102.1 72.9 125.1 108.7 96.6 70.5 ... 106.1 Singapore 96.5 88.2 69.1 94.2 96.0 91.2 70.0 ... 94.3 87.9 70.8 94.3 101.0 Sri Lanka 55.4 77.2 62.2 98.9 89.8 76.1 87.7 102.4 96.7 81.4 53.8 ... 94.5 Syria ... 99.7 87.1 67.9 103.1 99.9 89.7 62.1 103.3 100.3 91.1 65.5 102.7 Taiwan 98.7 99.3 83.7 98.3 94.9 86.4 62.8 86.5 95.7 85.7 61.0 ... 96.8 Tajikistan ... 86.5 78.6 45.4 99.4 90.6 73.5 46.6 100.8 95.1 81.0 46.4 96.4 Thailand ... 97.5 89.7 81.7 63.5 99.5 92.6 79.4 60.3 101.9 96.7 83.8 56.8 Timor-Leste ... 99.5 93.3 75.6 86.6 93.6 88.1 68.8 89.6 85.7 80.1 59.5 97.0 Turkey ... 87.2 74.1 102.4 98.6 88.3 66.5 103.2 100.1 89.2 64.4 101.7 98.9 Turkmenistan 56.9 82.0 56.7 98.6 95.0 78.6 89.9 99.5 95.2 83.9 55.2 ... 98.9 United Arab Emirates 360.3 335.6 180.4 106.4 337.1 281.3 ... 91.6 293.2 226.8 107.4 60.9 123.1 Uzbekistan 103.4 97.8 59.1 99.8 92.9 78.9 58.2 79.8 96.8 83.7 56.2 ... 91.1 Vietnam ... 87.9 68.7 44.7 104.4 97.1 78.1 46.0 109.5 102.9 89.6 57.1 100.4 West Bank ... 106.2 103.3 77.5 57.1 104.3 103.6 93.8 58.2 104.1 101.7 93.7 69.2 Yemen ... 86.6 88.0 78.1 102.8 100.8 75.9 63.9 100.2 95.9 93.7 54.3 105.7 Europe Albania 85.4 96.9 96.2 62.3 98.0 83.1 88.2 62.6 111.1 100.6 78.1 55.3 ... Andorra ... 113.8 109.2 85.5 103.7 101.9 104.3 88.3 104.1 104.3 91.5 76.8 104.5 Austria 59.9 ... 84.8 51.8 99.1 95.5 89.0 99.5 99.0 96.2 85.4 62.7 99.4 Belarus ... 95.0 81.9 53.7 29.2 100.4 85.9 60.5 29.8 104.3 95.3 72.7 35.2 Belgium 98.5 101.5 99.1 85.4 50.5 103.1 ... 88.0 56.6 102.6 100.4 89.1 59.3 Bosnia and Herzegovina 52.6 105.7 85.2 101.9 ... 100.2 94.8 73.0 34.1 102.9 96.4 82.3 41.2 149 An Aging World: 2015 U.S. Census Bureau

160 Table B-4. Sex Ratio for Population 35 Years and Over by Age: 2015, 2030, and 2050 —Con. (Men per 100 women) 2015 2030 2050 Country 80 and 80 and 50–64 65–79 80+ 35–49 50–64 65–79 50–64 over over 35–49 65–79 35–49 Europe —Con. Bulgaria 98.3 101.7 92.7 73.7 48.2 ... 97.0 83.3 48.9 102.4 73.1 51.0 87.7 Croatia 97.2 100.1 92.7 81.4 56.8 102.5 48.9 83.4 55.7 97.2 ... 78.2 94.0 Czech Republic 77.8 105.4 107.6 101.1 82.7 55.5 110.6 104.5 90.2 58.8 ... 96.5 49.0 Denmark 99.8 55.3 96.9 95.7 90.5 63.0 100.3 98.8 85.4 62.1 96.0 ... 90.5 Estonia 90.5 35.1 90.8 84.2 61.6 35.8 56.0 85.2 69.3 41.7 92.2 ... 79.0 Faroe Islands 108.2 104.9 67.1 ... 113.8 98.2 75.9 106.1 105.5 110.7 70.8 116.8 116.1 Finland 98.0 83.9 47.4 105.0 99.5 85.2 56.6 104.1 101.1 90.2 56.4 ... 103.8 France 101.5 54.5 102.7 98.2 85.3 61.9 102.9 100.3 90.7 60.2 94.4 ... 87.0 Germany 97.4 57.6 98.6 97.8 90.1 64.5 86.8 94.0 86.5 65.8 102.4 ... 100.0 Gibraltar 82.9 112.1 57.9 106.2 102.9 70.3 ... 103.2 105.1 92.7 52.8 105.6 76.6 Greece 97.0 85.0 63.3 97.7 97.6 87.5 61.7 97.2 95.6 88.4 63.1 ... 99.8 Guernsey 69.3 93.8 59.2 105.5 97.5 94.3 99.5 97.3 99.7 98.4 66.8 ... 99.1 Hungary 101.3 87.5 66.6 42.9 102.2 95.0 72.3 45.3 104.1 98.5 82.5 50.5 ... Iceland ... 101.2 94.2 67.3 100.6 99.8 92.9 70.6 99.1 97.8 91.5 66.6 101.7 Ireland ... 94.0 62.6 100.1 102.0 92.9 69.2 101.6 100.4 92.7 67.8 102.6 100.8 Isle of Man 98.4 66.2 100.7 99.0 96.0 76.2 110.9 103.4 91.3 71.8 102.3 ... 96.5 Italy 99.0 56.4 97.0 95.4 86.6 60.8 84.9 94.9 86.6 62.6 98.1 ... 95.0 Jersey 95.8 81.6 56.8 106.1 96.3 85.3 ... 107.9 102.8 93.7 60.2 98.7 57.2 Kosovo 103.7 75.1 59.8 111.5 107.6 91.9 54.5 106.6 106.6 96.8 67.8 ... 111.6 Latvia 31.5 56.1 29.1 98.9 93.0 66.3 83.5 100.9 94.9 78.0 42.7 ... 100.3 Liechtenstein 98.6 95.3 93.9 56.4 100.7 94.2 ... 73.9 109.2 94.2 85.0 64.6 85.1 Lithuania 100.2 86.8 35.7 101.6 93.8 72.6 39.1 105.2 98.4 81.6 49.4 ... 62.8 Luxembourg 99.8 87.0 46.9 97.9 96.8 88.0 56.0 ... 96.2 85.4 58.7 99.3 100.4 Macedonia 55.4 79.1 59.7 104.2 99.2 85.0 97.1 105.9 102.2 89.6 59.1 ... 103.1 Malta ... 99.4 88.6 58.9 105.6 102.9 92.3 67.2 105.5 104.0 96.8 65.3 104.6 Moldova 112.6 101.0 38.7 108.0 98.2 75.6 43.6 69.9 110.0 94.7 47.5 ... 85.9 Monaco ... 100.6 90.6 64.9 143.6 85.5 86.8 62.2 242.4 129.4 74.7 54.7 96.1 Montenegro ... 119.1 100.6 66.8 64.3 113.9 115.8 86.7 53.0 92.2 92.2 108.5 66.1 Netherlands ... 100.2 92.5 56.3 101.2 97.6 91.4 66.7 101.7 98.9 88.8 64.5 99.9 . . . . . . . . . . . . . . . . . . . . . . . 106.3 94.1 59.4 108.0 105.7 96.3 71.4 105.6 105.8 99.5 70.4 Norway 103.4 Poland 101.7 45.0 101.5 96.3 76.6 48.4 103.5 98.0 84.5 51.6 91.7 ... 71.7 Portugal 110.9 55.5 109.9 97.1 79.1 54.0 75.7 108.3 89.8 56.6 101.0 ... 89.2 Romania 90.2 72.0 55.9 104.2 96.3 75.1 ... 104.9 99.9 84.8 54.9 102.4 51.3 Russia 79.0 51.3 26.6 97.3 85.0 58.0 28.6 102.2 90.9 69.0 34.7 ... 95.8 San Marino 66.3 90.8 62.5 90.1 87.2 88.7 96.1 103.2 91.8 80.9 62.0 ... 87.3 Serbia 101.5 95.0 74.9 55.9 102.9 96.9 ... 53.3 104.8 100.7 85.3 56.2 80.4 Slovakia 101.4 92.4 41.8 102.5 96.0 77.4 45.9 103.5 98.6 84.6 51.6 ... 69.6 Slovenia 102.4 79.2 43.0 103.0 98.6 82.6 52.2 ... 100.3 88.2 54.4 104.7 97.5 Spain 58.9 83.6 56.6 105.2 99.7 86.6 96.6 104.7 101.8 91.3 62.4 ... 103.1 Sweden ... 101.5 94.8 60.9 101.6 100.5 95.2 71.3 102.0 98.8 93.7 68.5 103.0 Switzerland 100.8 100.6 55.7 100.0 98.8 92.7 65.0 88.2 98.4 90.3 66.9 ... 101.0 Ukraine ... 78.0 54.9 30.5 99.7 82.6 59.9 30.2 104.3 94.8 71.4 35.2 92.6 United Kingdom ... 104.9 98.3 89.3 62.0 105.1 102.8 90.5 66.8 105.1 102.8 95.6 66.8 Latin America and the Caribbean Anguilla 78.3 84.8 79.0 75.3 73.5 79.5 85.5 80.7 73.4 67.6 56.0 ... 104.1 Antigua and Barbuda 82.5 78.8 63.3 83.2 79.3 74.0 60.0 ... 82.7 71.3 53.9 87.1 82.2 Argentina 55.6 79.2 52.2 101.0 95.9 82.1 95.1 103.2 99.4 85.6 57.6 ... 99.2 Aruba 93.7 86.9 68.0 49.5 92.5 88.0 ... 46.8 94.4 89.3 79.5 50.3 76.4 Bahamas, The 103.1 100.4 45.4 102.6 96.0 74.1 46.4 66.3 99.9 85.9 56.0 ... 85.4 Barbados 99.8 90.8 72.7 47.9 99.0 95.9 ... 53.0 95.9 95.0 86.3 59.0 80.8 Belize 85.9 101.6 93.4 72.2 106.3 ... 97.6 66.3 106.9 103.3 90.0 60.6 97.2 Bolivia ... 92.5 82.9 64.3 98.4 88.5 77.5 62.3 100.5 95.4 82.7 54.9 86.7 Brazil ... 91.0 78.6 55.6 98.8 92.8 80.2 55.8 100.5 95.4 83.5 56.0 97.6 Cayman Islands ... 92.0 94.0 69.0 94.4 94.1 94.7 69.2 96.7 94.6 87.0 62.4 85.7 Chile ... 98.9 90.7 78.6 50.1 101.7 95.8 81.4 53.8 102.2 99.6 88.0 57.6 Colombia ... 90.1 74.5 58.6 100.5 93.2 96.9 51.6 103.2 98.5 85.7 56.9 81.1 Costa Rica ... 100.6 95.7 91.9 63.2 102.1 98.2 87.7 64.5 102.6 99.7 91.9 61.7 Cuba 98.0 101.4 94.3 86.5 62.3 102.6 ... 87.3 60.2 103.1 99.6 90.4 64.4 Curacao 104.2 102.5 53.3 48.9 92.1 ... 93.5 77.3 74.3 56.9 105.7 91.6 69.7 An Aging World: 2015 eau U.S. Census Bur 150

161 Table B-4. Sex Ratio for Population 35 Years and Over by Age: 2015, 2030, and 2050 —Con. (Men per 100 women) 2015 2030 2050 Country 80 and 80 and 50–64 65–79 80+ 35–49 50–64 35–49 over over 50–64 65–79 35–49 65–79 Latin America and the —Con. Caribbean Dominica 109.7 55.8 105.5 99.6 100.7 60.2 88.1 106.1 93.8 63.6 112.1 ... 101.5 Dominican Republic 102.1 90.8 67.5 105.2 102.7 92.9 65.8 103.8 102.8 ... 66.6 104.9 94.7 Ecuador 95.4 94.3 80.5 97.4 89.7 87.9 73.1 101.2 96.4 83.7 63.0 ... 92.7 El Salvador 81.6 82.6 67.7 91.3 78.2 72.2 ... 96.8 90.6 76.0 48.1 61.5 78.6 Grenada 67.4 89.2 67.3 100.4 109.4 94.9 106.2 106.4 97.7 94.1 66.0 ... 110.7 Guatemala 86.4 90.5 90.1 68.3 93.7 84.1 81.3 67.6 97.5 93.1 78.6 56.1 ... Guyana ... 74.0 56.9 109.2 104.5 74.7 48.2 101.4 102.4 92.5 55.2 110.1 87.1 Haiti 99.4 82.6 67.8 99.4 96.7 86.1 ... 100.2 97.3 87.4 65.4 64.4 94.4 Honduras 60.0 79.1 69.2 104.6 98.1 82.6 90.8 105.9 102.7 90.6 64.4 ... 101.7 Jamaica 97.3 95.1 87.6 63.9 101.3 95.6 85.9 63.5 102.4 100.5 88.5 62.6 ... Mexico ... 83.7 74.6 94.7 87.9 79.0 85.4 96.2 93.0 81.9 60.1 91.1 67.0 Montserrat 89.4 85.7 130.4 392.9 95.4 90.2 86.5 196.3 105.5 102.5 89.8 89.6 ... Nicaragua 87.1 77.3 86.3 84.6 68.1 92.9 84.0 ... 60.0 100.4 93.2 77.2 53.7 Panama ... 99.2 91.2 65.6 102.8 99.4 91.1 63.6 102.5 100.4 91.7 64.4 101.9 Paraguay ... 94.0 66.6 100.5 100.1 96.1 68.7 101.2 99.9 91.6 67.5 100.1 104.5 Peru 72.6 92.8 77.4 91.0 87.4 86.8 94.0 94.2 89.4 79.5 62.2 ... 91.0 Puerto Rico 90.9 84.0 80.1 63.9 96.5 90.0 ... 62.2 97.5 100.5 86.5 61.3 78.1 Saint Barthelemy 120.3 119.6 72.3 120.2 115.4 107.7 77.7 106.1 117.0 106.1 74.5 ... 119.2 Saint Kitts and Nevis ... 103.2 92.0 61.9 106.1 106.5 95.3 71.5 103.9 105.1 97.5 71.4 106.1 Saint Lucia ... 93.0 87.3 87.4 72.7 93.1 89.3 84.9 74.2 97.9 91.8 86.7 71.0 Saint Martin ... 88.8 86.6 56.9 94.6 83.6 78.6 59.1 91.9 92.7 76.6 53.0 83.6 Saint Vincent and the Grenadines .. 107.3 95.5 62.1 106.3 109.1 101.4 71.3 102.5 103.4 99.1 74.4 109.5 Sint Maarten ... 91.9 98.0 58.7 98.9 94.0 96.0 72.8 109.9 97.2 88.0 59.6 83.5 Suriname 58.0 ... 79.0 64.8 104.2 99.9 88.2 97.9 103.1 100.7 91.6 64.2 103.1 Trinidad and Tobago ... 110.3 100.9 83.8 49.3 111.2 107.9 87.6 54.3 109.0 110.1 96.8 57.7 104.8 Turks and Caicos Islands 106.2 115.1 83.1 72.6 96.4 . . . . . . . . . 103.0 62.3 100.7 95.2 92.3 74.3 Uruguay 54.0 ... 96.1 90.5 74.3 49.0 100.8 92.8 78.2 49.8 101.9 98.6 83.8 Venezuela 54.1 82.0 ... 94.9 95.8 91.3 82.8 61.1 97.5 91.9 80.4 57.5 101.3 Virgin Islands, British ... 95.2 99.2 75.8 86.6 85.0 87.7 77.9 85.9 84.2 78.5 63.1 87.0 Virgin Islands, U.S. ... 87.9 62.0 72.2 88.3 85.1 64.1 70.2 70.1 75.7 60.0 84.3 92.5 Northern America Bermuda 56.8 80.7 53.3 101.8 98.3 82.1 ... 102.0 98.1 90.7 57.4 91.2 101.3 Canada 102.2 99.2 89.5 59.8 103.7 100.8 ... 64.5 104.2 102.4 91.6 62.5 89.3 Greenland 105.2 114.1 63.9 104.8 112.1 104.6 89.3 126.8 101.1 89.2 69.1 ... 121.4 Saint Pierre and Miquelon ... 108.9 85.7 40.8 89.0 93.3 87.9 57.4 98.8 86.6 76.2 62.7 96.1 United States ... 99.0 94.4 86.1 60.7 102.5 96.0 87.0 68.5 104.3 101.0 90.1 68.5 Oceania American Samoa 85.5 112.0 55.6 106.4 108.4 77.5 57.3 90.8 99.3 102.7 53.2 ... 92.2 Australia 103.7 99.5 95.0 64.8 105.0 102.5 ... 70.2 106.3 103.9 95.5 66.3 91.7 Cook Islands 117.1 96.5 108.6 56.8 94.0 ... 119.2 57.8 106.8 100.9 85.4 72.5 103.5 Fiji 59.0 ... 88.9 59.5 105.1 104.5 91.6 102.5 103.5 102.5 93.9 60.6 105.4 French Polynesia ... 106.3 106.8 99.0 73.5 104.5 104.1 96.4 74.1 107.5 104.1 93.7 71.6 Guam 93.4 104.2 103.7 89.8 61.5 101.8 101.1 ... 61.4 104.2 102.1 89.5 64.4 Kiribati 44.4 ... 92.0 84.6 68.7 89.3 92.9 83.9 66.9 44.7 84.4 70.4 45.0 Marshall Islands ... 101.4 101.0 71.8 102.7 103.4 90.1 75.0 102.8 100.1 94.0 61.6 106.1 Micronesia, Federated States of ... 86.8 47.0 91.9 88.4 77.6 47.0 89.1 87.9 72.2 38.2 91.6 96.8 Nauru 30.6 64.6 45.5 104.2 90.6 51.0 70.7 72.2 97.0 77.9 35.4 ... 101.3 New Caledonia 101.3 96.5 86.5 56.6 102.4 97.3 ... 54.2 103.7 100.0 86.0 55.4 82.8 New Zealand 101.1 102.2 69.1 99.7 100.7 88.5 71.4 92.4 99.0 92.1 66.7 ... 95.6 Northern Mariana Islands ... 112.6 99.5 49.0 74.6 82.6 100.1 68.0 123.8 123.8 45.6 67.7 85.1 Palau ... 178.9 67.5 38.5 32.2 174.4 87.6 34.2 20.4 174.1 83.5 48.1 20.8 Papua New Guinea ... 106.8 105.3 110.8 102.8 103.1 93.9 74.6 103.9 100.1 88.0 67.4 108.1 Samoa ... 104.5 82.1 57.7 98.8 108.9 90.7 53.5 101.0 95.2 92.5 66.2 111.5 Solomon Islands ... 104.1 95.6 76.4 103.7 102.0 103.4 68.6 105.5 103.0 92.5 71.1 96.9 Tonga 62.2 ... 86.1 73.9 95.5 106.0 95.6 98.7 95.5 100.4 97.3 76.2 101.0 Tuvalu ... 83.1 71.1 69.7 64.8 120.0 76.3 58.1 51.7 105.3 111.7 77.3 47.5 Vanuatu 91.9 94.3 99.8 104.7 100.7 95.7 ... 91.9 82.8 94.9 93.4 85.4 68.1 Wallis and Futuna 113.2 95.9 55.9 ... 92.0 93.3 104.8 49.2 116.9 91.3 86.1 73.8 116.3 Source: U.S. Census Bureau, 2013; International Data Base. 151 An Aging World: 2015 U.S. Census Bureau

162 Table B-5. Dependency Ratios: 2015, 2030, and 2050 1 2 3 Total Older Youth Country 2015 2030 2050 2015 2030 2050 2015 2050 2030 Africa Algeria 9 62 59 45 75 16 30 ... 76 71 Angola 119 99 127 112 90 7 7 9 ... 134 Benin 134 82 127 100 71 7 7 11 ... 107 Botswana 91 75 83 70 60 ... 10 15 8 80 Burkina Faso 6 103 135 119 95 125 6 8 ... 141 Burundi 142 135 ... 136 128 106 6 7 9 115 Cameroon 84 70 75 56 45 9 15 27 ... 72 Cape Verde 129 91 122 104 81 ... 8 10 7 112 Central African Republic 8 88 112 97 78 105 8 10 ... 120 Chad ... 106 86 135 99 78 7 7 9 142 Comoros 9 122 114 70 52 69 9 16 ... 79 Congo (Brazzaville) ... 111 101 108 103 88 6 9 13 115 Congo (Kinshasa) ... 131 96 69 125 90 59 6 6 10 Cote d’Ivoire ... 83 69 103 75 56 7 7 13 110 Djibouti ... 65 81 61 50 7 8 16 88 69 Egypt 10 76 76 63 53 77 14 23 ... 85 Equatorial Guinea 122 98 75 113 89 ... 9 9 13 63 Eritrea 8 123 114 80 57 71 8 14 ... 88 Ethiopia ... 116 89 130 109 79 7 7 10 137 Gabon ... 131 125 105 122 115 96 9 9 9 Gambia, The ... 82 67 103 74 53 7 8 15 110 Ghana ... 101 91 102 90 76 9 11 15 110 Guinea ... 115 94 120 128 84 8 9 11 106 Guinea-Bissau 68 ... 79 108 90 98 7 8 11 115 Kenya ... 118 73 67 112 65 51 6 8 15 Lesotho 16 92 79 67 ... 68 51 10 11 82 Liberia 7 11 8 68 ... 132 102 79 125 95 Libya ... 78 58 46 44 7 12 34 65 58 Madagascar 120 113 89 61 7 9 13 98 ... 74 Malawi 6 132 112 81 7 89 8 139 ... 118 Mali 132 89 149 125 81 ... 7 8 157 8 Mauritania 95 78 107 86 64 8 9 14 ... 115 Mauritius 14 79 44 40 37 67 27 42 ... 58 Morocco 71 68 79 60 50 45 11 18 33 ... Mozambique ... 127 101 141 121 94 7 6 7 148 Namibia ... 58 81 55 43 9 10 15 90 65 Niger 7 92 161 131 85 137 7 8 ... 168 Nigeria 130 115 96 123 108 ... 7 7 9 87 Rwanda 6 122 116 93 84 96 7 12 ... 101 Saint Helena ... 68 98 36 32 36 22 36 62 59 Sao Tome and Principe ... 134 90 68 127 83 54 7 7 13 Senegal ... 127 103 81 121 95 69 7 8 12 Seychelles ... 53 71 41 32 26 11 21 44 53 Sierra Leone ... 105 117 107 94 8 8 11 125 115 Somalia 5 94 124 111 85 119 7 9 ... 130 South Africa 79 75 69 68 58 ... 12 16 19 50 South Sudan 5 141 136 100 67 77 6 10 ... 106 Sudan ... 83 67 113 75 53 7 8 14 120 Swaziland ... 105 80 67 97 71 56 8 9 11 Tanzania ... 116 95 131 109 85 7 7 10 138 Togo ... 106 91 110 98 79 7 9 12 117 Tunisia ... 70 86 49 62 41 13 23 45 46 Uganda 92 ... 99 158 133 138 5 5 7 163 Western Sahara ... 108 92 77 100 82 63 8 10 14 Zambia 130 146 136 116 140 ... 109 6 6 7 Zimbabwe 7 8 13 74 ... 110 101 87 103 93 See notes at end of table. An Aging World: 2015 eau U.S. Census Bur 152

163 Table B-5. Dependency Ratios: 2015, 2030, and 2050 —Con. 1 2 3 Total Older Youth Country 2015 2030 2050 2015 2030 2050 2015 2050 2030 Asia Afghanistan 6 123 101 72 107 6 8 ... 80 129 Armenia 70 84 40 37 32 17 33 52 ... 57 Azerbaijan 57 70 47 43 37 10 21 33 ... 64 Bahrain 42 50 38 34 33 ... 8 17 4 42 Bangladesh 10 71 78 54 46 67 13 25 ... 88 Bhutan 74 58 65 63 45 37 11 ... 28 13 Brunei 57 58 51 43 39 7 15 26 ... 65 Burma 68 71 59 49 45 ... 15 27 9 64 Cambodia 7 67 73 60 47 71 11 20 ... 81 China 50 62 82 35 34 ... 15 28 49 33 Cyprus 17 50 33 32 30 75 27 45 ... 59 Gaza Strip 126 85 64 120 77 ... 6 8 14 50 Georgia 36 64 81 39 ... 77 26 37 44 40 Hong Kong ... 48 81 101 25 31 30 23 50 71 India ... 67 70 66 53 45 10 15 25 76 Indonesia ... 74 59 47 41 11 18 33 70 65 Iran 8 70 49 43 37 57 14 34 ... 57 Iraq 100 76 71 93 67 52 7 9 19 ... Israel ... 80 77 65 55 45 20 24 32 85 Japan ... 91 121 32 30 33 48 62 89 80 Jordan ... 88 86 87 74 97 10 13 23 63 Kazakhstan ... 65 73 72 53 52 43 12 21 29 Korea, North ... 64 72 47 43 38 16 21 34 64 Korea, South ... 66 100 30 27 28 20 40 72 50 Kuwait ... 48 49 48 41 51 4 7 12 37 Kyrgyzstan ... 77 80 74 68 64 51 9 16 23 Laos ... 73 65 89 96 48 7 10 17 63 Lebanon. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 67 84 48 42 37 16 25 46 Macau 63 42 59 86 ... 25 24 14 34 28 Malaysia 77 28 55 ... 75 72 17 65 10 49 Maldives ... 58 63 47 45 35 7 13 28 53 Mongolia ... 69 58 51 40 7 14 28 65 64 Nepal 9 64 80 54 44 65 11 20 ... 88 Oman 75 69 63 70 62 46 6 7 17 ... Pakistan ... 68 64 84 58 45 8 11 18 93 Philippines ... 80 75 83 67 55 9 13 20 92 Qatar ... 24 29 20 22 21 1 2 5 23 Saudi Arabia ... 65 56 61 60 47 41 5 9 20 Singapore ... 51 68 29 28 28 13 23 40 41 Sri Lanka ... 71 80 54 46 42 15 25 38 69 Syria ... 69 69 82 58 89 8 11 23 46 Taiwan ... 48 64 93 30 26 26 18 38 68 Tajikistan ... 73 68 78 62 84 6 10 19 49 Thailand ... 52 62 85 37 33 34 15 29 51 Timor-Leste 97 130 107 74 121 ... 62 9 10 13 Turkey 63 ... 68 73 56 45 39 12 18 33 Turkmenistan ... 66 70 59 52 44 7 15 26 66 United Arab Emirates ... 41 36 38 37 1 2 5 37 40 Uzbekistan 8 65 55 45 36 60 15 30 ... 63 Vietnam 61 60 72 52 42 36 9 18 35 ... West Bank ... 72 65 85 61 44 7 11 21 92 Yemen ... 82 65 117 75 52 6 7 13 123 Europe Albania 64 70 72 45 ... 31 19 30 41 39 Andorra ... 53 126 30 26 37 22 45 89 71 Austria ... 79 94 31 32 35 32 46 58 62 Belarus ... 69 86 31 34 53 22 35 52 34 Belgium ... 68 81 88 35 36 36 32 45 52 Bosnia and Herzegovina ... 66 92 29 29 50 20 38 62 31 Bulgaria ... 63 72 102 30 30 34 32 42 68 Croatia 33 63 76 91 33 ... 34 30 43 56 Czech Republic 38 55 29 ... 60 69 90 31 31 35 See notes at end of table. 153 An Aging World: 2015 U.S. Census Bureau

164 Table B-5. Dependency Ratios: 2015, 2030, and 2050 —Con. 1 2 3 Total Older Youth Country 2015 2030 2050 2015 2030 2050 2015 2050 2030 Europe —Con. Denmark 32 40 39 38 ... 41 45 80 83 72 Estonia 80 104 34 36 38 31 44 66 ... 65 Faroe Islands 77 80 48 50 44 29 37 36 ... 87 Finland 72 88 37 39 37 ... 49 51 35 87 France 33 89 43 44 40 88 44 49 ... 76 Germany 65 84 94 29 33 35 35 ... 58 51 Gibraltar 74 74 47 45 38 27 29 39 ... 77 Greece 64 99 31 29 35 ... 43 64 34 72 Guernsey 31 86 33 34 35 76 42 51 ... 63 Hungary 62 71 92 33 32 ... 30 39 57 35 Iceland 23 67 44 43 39 83 35 44 ... 78 Ireland 67 71 84 46 43 ... 21 29 43 41 Isle of Man 36 72 89 38 ... 84 34 45 52 39 Italy ... 66 75 96 31 31 35 35 45 61 Jersey ... 78 73 37 41 35 26 37 38 63 Kosovo ... 66 60 46 38 12 17 28 72 62 Latvia 27 94 29 31 33 70 39 60 ... 56 Liechtenstein 61 78 82 34 36 35 27 42 48 ... Lithuania ... 71 94 29 30 32 27 41 62 56 Luxembourg ... 74 75 40 40 39 26 33 36 65 Macedonia ... 67 82 39 36 59 20 31 48 35 Malta ... 65 80 90 34 35 34 31 45 56 Moldova ... 72 86 37 39 36 18 33 49 55 Monaco ... 130 183 30 22 16 57 108 167 86 Montenegro ... 69 102 30 32 52 22 37 65 36 Netherlands ... 68 82 84 38 39 38 30 43 46 38 Norway 75 79 41 40 69 28 35 41 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poland ... 54 70 95 30 31 33 24 39 62 Portugal 60 67 72 94 ... 32 35 32 40 36 Romania 55 32 93 61 ... 24 61 33 31 28 Russia ... 81 32 36 35 21 34 47 53 70 San Marino 69 36 34 36 32 44 58 78 ... 95 Serbia 40 32 31 33 28 87 54 61 ... 71 Slovakia 67 92 32 31 34 22 35 58 ... 54 Slovenia ... 103 28 29 34 29 46 69 57 75 Spain 61 97 32 31 36 ... 37 62 29 68 Sweden 35 79 39 43 39 82 40 40 ... 73 Switzerland 36 74 81 33 ... 36 29 38 45 62 Ukraine 54 67 29 30 32 25 37 55 ... 87 United Kingdom 69 80 39 41 38 ... 38 42 30 79 Latin America and the Caribbean Anguilla 72 82 49 46 63 14 26 38 ... 44 Antigua and Barbuda 68 ... 75 55 48 42 13 22 33 70 Argentina ... 74 77 58 50 43 21 24 33 79 Aruba ... 74 78 39 39 59 20 35 41 37 Bahamas, The ... 63 66 75 51 45 40 12 21 35 Barbados ... 55 72 88 38 38 38 17 34 50 Belize ... 79 70 90 68 52 7 11 18 97 Bolivia ... 69 83 61 48 10 12 20 92 73 Brazil 13 74 52 41 38 62 21 37 ... 65 Cayman Islands 56 74 78 38 39 38 18 34 40 ... Chile ... 70 78 46 41 37 17 29 41 62 Colombia ... 67 71 57 46 38 12 21 33 69 Costa Rica ... 66 74 51 63 38 12 22 36 44 Cuba ... 55 87 35 32 34 20 33 53 65 Curacao ... 86 77 47 46 39 24 40 38 71 Dominica ... 72 90 49 44 67 18 28 53 37 Dominican Republic ... 79 74 76 66 54 46 13 20 31 Ecuador ... 69 70 68 51 81 13 18 29 41 El Salvador ... 82 65 70 69 47 36 13 18 33 Grenada 47 72 75 75 56 ... 38 17 28 37 Guatemala 11 49 9 17 ... 105 78 66 96 67 See notes at end of table. An Aging World: 2015 eau U.S. Census Bur 154

165 Table B-5. Dependency Ratios: 2015, 2030, and 2050 —Con. 1 2 3 Total Older Youth Country 2015 2050 2015 2030 2050 2015 2050 2030 2030 Latin America and the Caribbean —Con. Guyana 61 72 46 38 10 16 23 82 ... 62 Haiti 69 65 87 ... 48 8 10 17 95 60 Honduras 74 68 89 63 49 8 11 20 ... 97 Jamaica 15 64 72 53 40 69 16 24 ... 87 Mexico 77 71 74 65 53 43 12 ... 31 18 Montserrat 62 48 52 32 31 10 16 44 ... 75 Nicaragua 80 64 71 48 37 ... 13 27 9 62 Panama 14 74 64 52 42 72 20 32 ... 78 Paraguay ... 65 69 62 47 39 12 18 30 73 Peru 12 76 64 51 41 70 18 29 ... 69 Puerto Rico ... 81 93 43 38 35 30 44 58 73 Saint Barthelemy ... 54 75 83 31 28 29 23 47 54 Saint Kitts and Nevis ... 68 86 45 40 37 13 28 50 58 Saint Lucia ... 108 48 37 32 18 34 76 66 72 Saint Martin 12 76 51 49 48 70 21 29 ... 63 Saint Vincent and the Grenadines 65 67 83 50 ... 36 15 28 47 39 Sint Maarten 52 79 40 44 38 12 38 42 ... 82 Suriname 68 59 70 59 43 38 10 16 32 ... Trinidad and Tobago ... 54 90 39 37 36 15 33 54 70 . . . . . . . . . . . . . . . 37 51 76 43 38 Turks and Caicos Islands 6 13 38 50 Uruguay ... 71 75 50 42 75 25 29 38 37 Venezuela ... 76 71 73 66 54 46 11 17 26 Virgin Islands, British ... 58 72 34 46 38 12 24 34 35 Virgin Islands, U.S. 33 ... 94 131 39 72 35 34 61 96 Northern America Bermuda ... 50 67 52 28 94 89 39 42 39 Canada ... 83 87 35 38 38 29 46 49 64 Greenland 14 70 47 47 39 77 30 31 ... 60 Saint Pierre and Miquelon 66 84 135 35 30 36 31 54 100 ... United States ... 82 81 43 45 43 25 37 38 68 Oceania American Samoa 61 66 78 52 ... 38 8 21 41 44 Australia ... 65 74 78 40 40 38 26 34 40 Cook Islands ... 79 92 54 42 41 20 37 51 74 Fiji ... 70 73 63 52 43 11 19 30 74 French Polynesia ... 64 75 51 63 36 12 22 38 42 Guam 41 ... 74 60 51 77 16 26 32 76 Kiribati ... 86 68 66 78 57 47 8 11 19 Marshall Islands 22 99 75 70 ... 63 48 7 12 91 Micronesia, Federated States of 68 78 ... 84 69 21 11 57 47 6 Nauru ... 78 72 61 57 4 10 21 75 72 New Caledonia 15 71 53 43 38 63 20 33 ... 68 New Zealand 70 80 82 45 44 40 25 36 42 ... Northern Mariana Islands ... 74 52 39 30 64 25 44 60 8 Palau 57 67 79 45 41 40 11 26 39 ... Papua New Guinea 66 96 77 71 88 18 52 8 11 ... Samoa ... 73 69 84 58 46 11 16 23 95 Solomon Islands ... 77 71 93 67 102 8 10 20 50 Tonga ... 108 78 76 95 63 42 13 15 34 Tuvalu ... 86 69 71 81 53 10 17 16 69 Vanuatu 67 ... 78 70 97 104 50 8 11 19 Wallis and Futuna 25 ... 68 65 79 53 40 33 16 46 1 Total dependency ratio is the number of people aged 0 to 19 years and 65 years and over per 100 people aged 20 to 64. Youth and older ratios may not sum to total ratio due to rounding. 2 Youth dependency ratio is the number of people aged 0 to 19 per 100 people aged 20 to 64. 3 Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64. Source: U.S. Census Bureau, 2013; International Data Base. 155 An Aging World: 2015 U.S. Census Bureau

166 Table B-6. Life Expectancy at Birth, Age 65, and Age 80 by Sex for Selected Countries: 2015 and 2050 (In percent) Life expectancy at birth Life expectancy at 65 Life expectancy at 80 2015 2015 2050 2050 2050 2015 Country Both Both sexes Male Female Male Female Male Female Male Female sexes Female Male Female Male Japan 81.4 91.6 88.4 95.0 20.0 25.2 25.0 88.3 9.4 12.6 12.6 16.8 ... 84.7 30.6 Singapore 82.1 87.5 ... 88.7 94.6 20.6 24.5 25.5 30.3 11.5 12.9 14.1 16.9 84.7 91.6 Macau 81.6 87.6 85.1 82.2 88.1 20.2 24.9 20.7 25.3 10.1 13.4 10.5 13.8 ... 84.5 Hong Kong 20.1 85.8 84.4 81.6 87.4 18.9 23.1 80.2 24.6 8.5 10.9 9.8 12.8 ... 82.9 Switzerland 82.5 80.2 84.9 84.2 81.6 87.0 19.0 22.4 20.1 24.3 8.4 10.4 9.7 12.6 ... Australia ... 84.7 84.1 81.4 86.9 19.0 22.5 20.1 24.3 8.9 11.0 9.9 12.8 82.2 79.7 Italy 82.1 84.9 84.1 81.3 87.0 18.6 22.4 ... 24.3 8.7 10.7 9.8 12.7 20.0 79.5 Sweden 20.0 84.0 84.0 81.5 86.6 18.6 21.5 80.1 23.9 7.9 9.8 9.5 12.3 ... 82.0 Canada 81.8 79.2 84.5 83.9 81.1 86.8 18.9 22.7 20.1 24.4 9.4 11.6 10.1 13.0 ... France ... 85.0 83.9 80.9 87.0 18.9 22.9 78.7 24.5 8.6 10.8 9.7 12.7 81.8 20.0 19.9 81.7 79.7 83.8 83.9 81.4 86.5 18.5 21.3 Norway 23.8 8.1 9.8 9.6 12.3 . . . . . . . . . . . . . . . . Spain ... 81.6 78.6 84.8 83.8 80.9 86.9 18.2 22.2 19.8 24.2 8.3 10.1 9.6 12.5 Israel ... 79.1 83.7 83.8 81.1 86.5 18.4 21.4 19.9 23.9 8.6 10.3 9.8 12.5 81.4 Netherlands 19.7 83.5 83.7 81.1 86.4 17.9 21.4 79.1 23.9 8.0 10.0 9.6 12.3 ... 81.2 New Zealand 81.1 79.0 83.2 83.6 81.1 86.3 18.6 21.4 19.9 23.8 8.9 10.4 9.9 12.5 ... Ireland ... 78.4 83.1 83.4 80.8 86.2 17.7 21.0 19.6 23.7 8.1 9.8 9.6 12.3 80.7 Germany ... 78.3 83.0 83.4 80.7 86.2 17.9 80.6 19.6 23.6 8.3 9.6 9.7 12.2 20.9 Jordan ... 80.5 79.1 82.1 83.4 81.1 85.8 18.0 20.2 19.5 23.2 7.8 9.0 9.3 11.8 United Kingdom ... 78.4 82.8 83.4 80.8 86.1 18.0 20.9 19.7 23.6 8.4 10.1 9.7 12.4 80.5 Greece ... 77.8 83.2 83.3 80.6 86.3 17.6 80.4 19.5 23.7 8.3 10.1 9.6 12.4 20.9 Austria ... 80.3 77.4 83.4 83.3 80.3 86.4 17.5 21.3 19.4 23.8 8.1 10.0 9.5 12.3 Belgium ... 76.9 83.4 83.2 80.1 86.3 16.9 80.1 19.2 23.8 7.8 10.3 9.4 12.5 21.4 Korea, South 21.1 ... 77.0 83.3 84.2 81.5 87.1 17.1 80.0 20.2 24.4 7.8 9.8 10.1 13.0 Taiwan 12.5 ... 80.0 76.9 83.3 83.1 80.1 86.3 17.7 21.4 19.5 23.8 8.4 10.4 9.6 6.1 5.5 8.3 6.9 Rwanda ... 59.7 58.1 61.3 72.0 69.6 74.4 13.0 14.1 15.2 17.6 Congo (Brazzaville) ... 60.0 71.1 69.0 73.2 13.2 14.3 15.4 17.7 5.6 6.0 7.0 8.4 58.8 57.6 Liberia 58.6 70.7 68.3 73.2 12.0 13.5 14.5 17.2 5.1 5.7 6.6 8.1 56.9 ... 60.3 Cote d’Ivoire 17.8 69.7 68.0 71.4 12.2 13.8 15.0 59.5 5.3 6.0 6.9 8.6 58.3 ... 57.2 Cameroon 56.6 59.3 72.0 69.7 74.4 12.9 14.0 ... 17.6 5.5 6.0 6.9 8.3 57.9 15.3 Sierra Leone 55.2 60.4 70.2 67.1 73.3 12.5 13.9 14.7 17.4 5.3 5.9 6.6 8.1 ... 57.8 Zimbabwe 17.4 57.6 67.2 66.9 67.5 14.4 17.0 56.5 21.0 6.9 8.2 8.6 11.0 ... 57.1 Congo (Kinshasa) 56.9 55.4 58.5 70.2 67.8 72.7 11.7 13.1 14.2 16.7 5.0 5.6 6.4 7.8 ... Angola 55.6 54.5 69.2 67.1 71.5 12.4 13.4 14.5 16.5 5.2 5.7 6.5 7.6 ... 56.8 Mali 13.7 57.3 68.4 65.7 71.1 11.7 12.8 ... 16.0 4.8 5.3 6.0 7.2 55.3 53.5 Burkina Faso 55.1 53.1 57.2 67.8 65.1 70.5 11.7 13.1 ... 16.5 4.9 5.5 6.1 7.6 13.8 Niger 16.1 55.1 68.2 66.1 70.5 12.3 13.1 14.3 56.4 5.1 5.5 6.3 7.3 ... 53.9 Uganda ... 53.5 56.4 67.8 65.6 70.0 13.4 14.4 15.1 17.4 5.7 6.2 6.6 8.0 54.9 Botswana ... 54.2 56.0 52.3 61.6 64.8 58.4 15.1 18.3 18.5 21.7 8.2 10.0 10.1 12.7 Malawi 54.4 ... 53.5 52.7 65.3 64.0 66.5 12.0 13.4 14.0 16.5 5.1 5.8 6.5 8.0 Nigeria ... 52.0 54.1 68.1 66.0 70.3 12.1 13.1 14.2 16.2 5.2 5.6 6.3 7.5 53.0 Lesotho ... 53.0 72.3 71.5 73.2 12.8 14.9 15.9 18.5 5.9 6.9 7.7 9.7 52.9 52.8 Mozambique 14.7 53.7 70.8 69.0 72.7 12.0 13.5 52.2 17.2 5.3 6.0 6.8 8.4 ... 52.9 Zambia 52.2 50.5 53.8 64.5 62.5 66.7 12.4 ... 14.0 16.2 5.3 5.8 6.0 7.3 13.7 Gabon 15.4 52.0 62.1 61.6 62.6 12.4 14.7 52.5 19.0 5.7 6.8 7.5 9.7 ... 51.6 Somalia 12.8 52.0 54.1 65.5 62.6 68.5 11.7 49.9 13.5 15.6 4.9 5.4 5.9 7.1 ... Central African Republic .. 51.8 53.2 65.5 63.5 67.7 12.0 13.2 14.0 16.2 5.2 5.8 6.4 7.7 50.5 Namibia ... 52.1 51.2 57.8 60.1 55.5 13.0 15.6 15.3 18.6 6.2 7.4 7.9 10.3 51.6 Swaziland ... 51.6 50.5 61.4 63.0 59.8 12.9 51.1 15.3 18.2 6.0 7.1 7.6 9.8 15.4 Afghanistan ... 50.9 49.5 52.3 64.5 62.2 66.9 11.0 12.1 13.0 15.0 4.6 5.1 5.7 6.8 Guinea-Bissau ... 48.2 52.3 63.5 61.0 66.2 11.4 50.2 13.5 16.2 5.0 5.7 6.1 7.7 12.9 Chad 12.8 ... 48.6 51.0 63.4 61.7 65.1 11.7 49.8 13.8 15.7 5.0 5.5 6.2 7.3 South Africa 6.2 7.7 8.2 10.7 ... 49.7 50.7 48.7 63.2 64.1 62.3 13.0 15.7 16.3 20.0 Source: U.S. Census Bureau, International Data Base; unpublished lifetables. An Aging World: 2015 eau U.S. Census Bur 156

167 Table B-7. Deficits in Universal Health Protection: Share of Total Population Without Health Protection by Country Percent of total Region or country population Year of estimate Africa Algeria ... 14.8 2005 Angola 100.0 2005 ... Benin 2009 ... 91.0 Burkina Faso ... 99.0 2010 Burundi ... 2009 71.6 Cabo Verde 35.0 2010 ... Cameroon 2009 ... 98.0 Central African Republic 94.0 2010 ... Comoros 2010 95.0 ... Congo (Kinshasa) 90.0 2010 ... Cote d’Ivoire 2008 ... 98.8 Djibouti ... 70.0 2006 Egypt ... 48.9 2008 Eritrea 95.0 2011 ... Ethiopia ... 95.0 2011 Gabon 42.4 2011 ... Gambia 2011 0.1 ... Ghana 26.1 2010 ... Guinea 2010 99.8 ... Guinea Bissau 98.4 2011 ... Kenya 60.6 2009 ... Lesotho 82.4 2009 ... Libya ... 0.0 2004 Madagascar 96.3 2009 ... Mali ... 98.1 2008 Mauritania 94.0 2009 ... Mauritius ... 0.0 2010 Morocco ... 57.7 2007 Mozambique ... 96.0 2011 Namibia ... 2007 72.0 Niger ... 96.9 2003 Nigeria 97.8 ... 2008 Rwanda ... 9.0 2010 Sao Tome and Principe 2009 ... 97.9 Senegal 79.9 2007 ... Seychelles ... 10.0 2011 Sierra Leone 100.0 ... 2008 Somalia 80.0 2006 ... South Africa 0.0 2010 ... Sudan 70.3 2009 ... Swaziland ... 2006 93.8 Tanzania ... 87.0 2010 Togo ... 96.0 2010 Tunisia ... 20.0 2005 Uganda ... 2008 98.0 Zambia ... 2008 91.6 Zimbabwe ... 99.0 2009 Latin America and the Caribbean Antigua and Barbuda 48.9 2007 ... Argentina ... 2008 3.2 Aruba ... 0.8 2003 Bahamas ... 0.0 1995 Barbados ... 0.0 1995 Belize ... 75.0 2009 Bolivia ... 57.3 2009 Brazil ... 0.0 2009 Chile 6.9 2011 ... Colombia ... 12.3 2010 Costa Rica ... 0.0 2009 Cuba 2011 ... 0.0 Dominica ... 2009 86.6 157 An Aging World: 2015 U.S. Census Bureau

168 Table B-7. Deficits in Universal Health Protection: Share of Total Population Without Health Protection by Country —Con. Percent of total Region or country population Year of estimate —Con. Latin America and the Caribbean Dominican Republic 73.5 2007 ... Ecuador 2009 ... 77.2 El Salvador 78.4 ... 2009 Guatemala 70.0 2005 ... Guyana ... 76.2 2009 Haiti 96.9 ... 2001 Honduras 88.0 2006 ... Jamaica 2007 ... 79.9 Mexico 14.4 2010 ... Nicaragua 87.8 2005 ... Panama ... 48.2 2008 Paraguay 76.4 2009 ... Peru ... 35.6 2010 Saint Kitts and Nevis ... 2008 71.2 Saint Lucia ... 2003 64.5 Saint Vincent and the Grenadines ... 90.6 2008 Uruguay 2.8 2010 ... Venezuela ... 0.0 2010 Northern America Canada ... 0.0 2011 United States ... 16.0 2010 Asia Armenia 0.0 ... 2009 Azerbaijan 97.1 ... 2006 Bahrain ... 0.0 2006 Bangladesh ... 2003 98.6 Bhutan ... 10.0 2009 Brunei ... 0.0 2010 Cambodia 2009 ... 73.9 China ... 2010 3.1 Cyprus ... 2008 35.0 Georgia ... 2008 75.0 Hong Kong ... 0.0 2010 India 87.5 2010 ... Indonesia ... 2010 41.0 Iran ... 10.0 2005 Israel ... 0.0 2011 Japan ... 0.0 2010 Jordan ... 25.0 2006 Kazakhstan ... 30.0 2001 Korea, South ... 0.0 2010 Kuwait 0.0 2006 ... Kyrgyzstan ... 17.0 2001 Laos ... 88.4 2009 51.7 Lebanon. . . . . . . . . . . . . . . . . . . . . . . . . . . 2007 Malaysia ... 2010 0.0 Maldives ... 2011 70.0 Mongolia ... 18.1 2009 Nepal 99.9 2010 ... Oman ... 2005 3.0 Pakistan ... 73.4 2009 Philippines ... 18.0 2009 Qatar ... 0.0 2006 Saudi Arabia ... 74.0 2010 Singapore ... 0.0 2010 Sri Lanka ... 0.0 2010 Syria 10.0 2008 ... Tajikistan ... 99.7 2010 Thailand ... 2.0 2007 Turkey ... 2011 14.0 Turkmenistan 2011 17.7 ... An Aging World: 2015 eau U.S. Census Bur 158

169 Table B-7. Deficits in Universal Health Protection: Share of Total —Con. Population Without Health Protection by Country Percent of total Region or country Year of estimate population Asia —Con. United Arab Emirates ... 0.0 2010 Uzbekistan 2010 ... 0.0 Vietnam ... 39.0 2010 Yemen 58.0 2003 ... Europe Albania 76.4 ... 2008 Austria ... 0.7 2010 Belarus 0.0 2010 ... Belgium ... 1.0 2010 Bosnia and Herzegovina ... 40.8 2004 Bulgaria ... 13.0 2008 Croatia ... 2009 3.0 Czech Republic ... 2011 0.0 Denmark ... 0.0 2011 Estonia 7.1 ... 2011 Finland ... 0.0 2010 France ... 0.1 2011 Germany ... 0.0 2010 Greece ... 0.0 2010 Hungary ... 0.0 2010 Iceland ... 2010 0.0 Ireland ... 0.0 2011 Italy ... 0.0 2010 Latvia 30.0 2005 ... Liechtenstein ... 2008 5.0 Lithuania ... 5.0 2009 Luxembourg 2.4 ... 2010 Macedonia ... 5.1 2006 Malta 2009 ... 0.0 Moldova ... 24.3 2004 Montenegro 5.0 ... 2004 Netherlands 1.1 ... 2010 Norway . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0 2011 Poland 2.5 2010 ... Portugal ... 0.0 2010 Romania ... 5.7 2009 Russia ... 12.0 2011 Serbia ... 2009 7.9 Slovakia ... 2010 5.2 Slovenia 0.0 2011 ... Spain 0.8 2010 ... Sweden ... 0.0 2011 Switzerland ... 0.0 2010 Ukraine 0.0 2011 ... United Kingdom ... 0.0 2010 Oceania Australia ... 0.0 2011 Fiji ... 0.0 2010 New Zealand ... 0.0 2011 Vanuatu 0.0 ... 2010 Source: Scheil-Adlung, Xenia (ed.) 2015. Global Evidence on Inequities in Rural Health Protection: . International Labour Office Extension of New Data on Rural Deficits in Health Coverage for 174 Countries Social Security (ESS) Document 47, Statistical Annex. Geneva: International Labour Organization. 159 An Aging World: 2015 U.S. Census Bureau

170 Table B-8. Labor Force Participation Rates by Age, Sex, and Country: Selected Years, 1980 to 2012 (In percent) Female Male Country 55 to 59 65 years 45 to 49 45 to 49 60 to 64 55 to 59 60 to 64 65 years 50 to 54 50 to 54 years years years years years years and over and over years years Year Africa Egypt 94.2 91.3 88.8 68.3 25.5 6.0 4.3 3.4 2.0 0.7 ... 1986 4 8 4 8 1995 36.5 98.1 25.5 N 97.9 16.0 6.6 2.1 76.4 N 4 8 8 4 1999 32.1 98.1 22.3 N 97.9 N 5.6 2.3 63.5 14.2 7 9 7 9 2012 N 21.5 95.0 N N 28.1 15.5 N 2.4 69.1 Morocco ... 93.3 89.5 68.9 42.1 14.1 14.6 14.6 11.2 5.3 1982 96.6 10 5 10 5 1990 N 90.3 17.1 N N N N 8.9 38.1 N 10 5 10 5 1999 30.1 43.7 90.0 N N N N N 13.0 N 10 5 10 5 2005 40.0 N N N N N N 12.5 87.6 30.4 95.3 89.1 79.8 51.1 28.7 31.6 31.2 27.9 19.2 8.5 2012 11 11 Mozambique 91.9 89.8 90.0 88.4 83.0 87.2 ... 89.9 89.0 85.4 1997 89.9 2012 79.8 81.6 81.5 75.3 90.5 86.9 81.7 81.1 68.9 81.9 9 9 South Africa 24.1 77.3 N 34.7 N N N N N 5.9 ... 1980 9 9 N N 1991 21.3 N N 5.2 28.5 N 70.5 N 80.8 40.6 63.5 2003 25.6 62.6 50.9 38.4 15.2 9.6 73.7 82.6 54.3 66.1 31.8 N 62.1 2012 42.9 18.7 N 75.6 Tunisia 38.5 96.2 92.8 82.1 59.2 ... 12.9 11.6 9.8 4.4 3.5 1984 1994 95.6 90.1 78.3 54.6 31.5 17.6 12.6 9.6 7.3 3.3 1997 95.6 78.4 54.1 34.0 21.6 14.4 12.2 7.7 3.5 90.4 94.1 11.5 70.1 34.4 15.4 23.5 16.6 2012 4.8 1.9 88.2 11 11 Zambia 65.3 97.8 96.5 ... 1980 41.5 46.8 49.5 57.0 97.7 23.6 98.4 2008 97.2 95.2 90.5 88.5 72.0 85.6 85.3 83.5 79.4 56.3 77.8 2012 88.9 89.6 71.2 84.1 84.3 96.8 74.3 52.2 96.9 5 5 Zimbabwe 93.9 92.5 90.4 N ... 69.1 52.4 50.6 50.7 N 31.5 1982 21.7 1992 95.1 92.2 88.8 77.5 52.0 54.0 49.7 47.1 40.0 95.6 60.7 77.8 87.8 1999 78.8 94.2 84.4 84.1 74.1 83.0 2011 94.1 94.6 88.9 72.6 89.3 87.0 86.0 84.3 63.0 96.8 Asia Bangladesh 93.6 90.6 90.7 84.7 68.7 4.4 4.7 4.4 4.5 3.6 1981 ... 10.8 99.3 93.4 70.4 10.3 98.0 9.8 9.0 10.9 99.7 1986 99.5 99.2 97.3 87.8 66.1 2003 19.9 17.1 13.4 8.7 22.6 2010 94.1 88.5 77.2 57.9 50.1 9.4 10.5 6.6 8.3 97.4 China ... 97.5 91.4 83.0 63.7 1982 70.6 50.9 32.9 16.9 4.7 30.1 1990 97.9 93.5 83.9 63.7 33.6 81.1 62.0 45.1 27.4 8.4 2000 94.2 79.6 60.2 33.7 78.5 66.8 54.5 38.9 17.2 89.3 N 95.1 80.4 2010 N 80.1 62.4 53.8 40.6 89.8 58.3 8 4 5 8 4 5 India 93.8 N 1981 65.5 14.3 37.0 N 98.1 30.3 N N ... 4 11 12 8 4 11 12 8 1991 92.6 41.5 N N 96.9 71.4 20.8 35.5 8.2 42.3 8 12 11 4 4 11 8 12 2001 40.9 45.4 47.3 N 92.0 69.7 N 26.3 97.0 12.0 96.0 2012 98.5 73.4 91.5 46.3 41.1 37.5 33.3 26.2 11.5 Indonesia 1982 87.4 76.8 57.9 56.7 93.0 50.4 39.3 23.2 97.2 ... 51.1 93.8 89.6 79.7 56.8 60.5 57.7 52.2 42.7 25.1 1992 97.6 5 5 95.7 N 87.6 98.0 1999 54.3 N 66.5 34.0 62.2 60.0 5 5 91.2 N 2005 98.6 97.0 59.9 68.5 61.8 36.6 57.4 N 61.4 95.0 97.6 69.0 63.7 88.4 58.3 47.3 39.8 2010 78.9 Israel 43.2 1983 89.1 84.2 78.2 32.2 51.1 91.5 36.7 22.0 9.2 ... 7 7 1996 N 75.9 59.0 16.9 87.4 65.8 N 44.7 19.9 5.1 7 2006 N 60.2 16.5 70.6 N 58.3 32.6 5.2 84.0 76.5 87.3 2012 79.3 71.1 24.8 75.6 74.9 66.4 48.2 10.4 84.4 Japan ... 1980 98.0 97.3 94.0 81.5 46.0 62.3 58.7 50.7 38.8 16.1 70.7 1989 91.6 71.4 35.8 96.0 64.2 52.2 39.2 15.7 97.6 1999 97.5 97.1 94.7 74.1 35.5 71.8 67.9 58.7 39.8 14.9 29.3 2006 95.7 93.2 70.9 96.9 74.0 70.5 60.3 40.2 13.0 45.8 13.4 73.4 64.6 2012 96.1 95.0 92.2 75.4 28.7 75.7 See notes at end of table. An Aging World: 2015 eau U.S. Census Bur 160

171 Table B-8. —Con. Labor Force Participation Rates by Age, Sex, and Country: Selected Years 1980 to 2012 (In percent) Male Female Country 55 to 59 55 to 59 50 to 54 60 to 64 65 years 65 years 60 to 64 45 to 49 45 to 49 50 to 54 years years years and over years years and over years years years Year —Con. Asia Malaysia 92.2 78.1 69.5 ... 42.3 37.7 32.6 26.7 19.0 1980 96.1 49.7 87.1 53.3 31.8 35.8 29.6 20.6 14.6 6.7 1991 92.4 65.0 28.5 75.1 N 49.6 40.6 61.6 23.2 N 98.0 2000 93.4 92.5 76.8 57.4 N 55.3 48.3 34.6 21.2 N 2012 96.9 5 5 Pakistan 1981 N 90.4 75.7 2.7 3.1 2.4 N 92.0 2.3 ... 93.9 96.5 1994 52.7 15.6 13.9 15.3 11.8 7.4 91.5 97.2 78.8 22.8 95.8 49.3 26.5 22.5 77.5 19.1 11.5 97.6 2006 90.7 96.6 92.2 78.0 41.6 28.6 2011 26.3 21.0 10.6 97.8 28.1 7 9 7 9 Philippines 88.9 N 59.0 97.4 58.2 1989 N 50.7 N 29.4 ... N 7 9 7 9 1999 N 54.5 96.8 64.0 N N 55.8 N 29.8 88.1 7 9 7 9 2006 80.6 N 50.6 N 63.3 N 93.8 54.1 N 28.7 2010 95.0 86.1 73.4 62.4 65.5 63.9 59.9 49.6 40.6 91.7 Singapore ... 89.6 70.7 52.5 28.6 26.5 20.4 14.5 11.3 6.4 1980 95.7 30.7 89.2 48.2 20.7 41.3 66.6 19.4 11.0 5.0 1989 96.1 96.3 91.3 74.4 49.6 18.5 2000 46.7 29.6 15.3 4.1 57.4 2006 93.3 81.9 62.5 22.0 66.2 59.5 44.6 26.2 8.3 96.5 65.6 2012 88.5 74.6 32.4 73.4 93.8 56.2 41.7 13.7 95.6 South Korea ... 1989 93.6 89.7 82.4 65.6 39.0 63.5 60.4 52.7 41.6 18.1 1999 93.0 81.0 65.5 40.2 62.8 55.4 51.2 46.3 21.4 89.9 64.4 2006 79.9 68.5 42.0 89.7 58.5 49.7 43.8 22.7 93.1 2012 93.0 91.4 84.7 72.3 41.6 67.7 62.5 54.8 43.9 23.0 Sri Lanka 25.2 92.3 87.4 74.3 56.6 35.7 1981 19.3 13.2 6.9 3.8 ... 5 5 91.8 73.0 N 1996 91.9 39.0 32.3 27.2 N 38.6 7.8 5 5 95.6 88.8 76.8 N 2000 31.6 N 40.6 47.1 36.4 10.2 2012 94.4 81.0 64.9 35.5 45.3 41.8 36.6 22.4 9.3 90.5 Thailand ... 90.7 84.4 67.8 39.3 93.7 68.6 59.1 43.1 19.0 1980 73.5 8 5 4 4 8 5 1994 23.5 76.7 N N 63.8 N 97.5 92.8 N 47.2 5 4 4 8 8 5 2006 52.2 83.6 92.0 N N 71.3 N 96.7 27.3 N 77.7 96.9 90.5 73.7 38.8 83.6 2012 70.9 52.0 19.9 95.0 Turkey ... 1980 91.1 84.9 76.8 67.4 43.9 48.3 46.1 42.4 36.3 20.8 1988 89.2 71.5 59.2 33.8 36.3 36.4 29.4 20.9 10.9 82.7 83.0 29.7 60.3 54.0 33.6 1996 29.3 30.4 23.4 13.3 71.0 24.8 2006 51.3 39.8 22.0 65.4 21.8 18.5 14.5 6.6 82.0 2012 86.1 68.7 53.7 41.9 20.1 33.1 26.2 20.0 16.0 6.4 Europe Austria ... 1981 96.3 91.5 77.3 23.3 3.1 57.3 53.5 32.4 9.5 1.8 65.1 1991 89.8 63.1 12.3 1.7 95.1 56.3 23.1 4.9 0.7 63.2 1998 93.6 88.4 63.6 13.2 4.4 72.6 24.8 8.4 1.9 2006 93.1 69.1 21.9 5.5 82.6 75.0 41.9 10.1 2.2 87.6 93.1 90.4 29.7 7.3 85.8 80.0 53.9 14.3 3.5 2012 76.4 Belgium 38.2 85.7 70.7 32.3 3.3 ... 30.7 17.3 5.7 1.0 1981 90.8 90.5 81.6 49.2 18.4 1.9 1997 44.2 21.8 4.6 0.7 59.5 2006 85.2 58.3 22.6 2.7 72.8 61.1 36.2 10.3 1.0 91.4 69.7 2012 66.8 26.8 4.0 78.8 86.6 51.0 17.2 1.1 90.8 Bulgaria ... 1985 94.6 88.1 80.9 39.2 15.2 91.0 83.6 32.0 16.5 4.3 2006 84.1 66.1 38.6 4.6 82.8 76.5 53.4 11.7 1.5 79.2 80.7 2012 69.8 44.4 4.5 85.1 81.2 69.5 22.7 1.9 83.4 Czech Republic ... 1980 96.0 92.7 84.2 46.3 19.5 88.1 79.9 40.8 21.5 6.5 93.4 1991 80.0 28.4 11.6 91.5 85.7 31.1 16.2 4.9 95.5 1999 94.9 90.1 77.1 27.5 7.2 90.8 81.5 33.2 12.9 2.7 6.6 2006 90.6 83.1 36.1 94.6 91.8 88.2 51.2 13.1 2.5 3.3 66.5 17.2 2012 95.6 93.8 86.4 41.0 6.8 93.8 90.0 See notes at end of table. 161 An Aging World: 2015 U.S. Census Bureau

172 Table B-8. Labor Force Participation Rates by Age, Sex, and Country: Selected Years 1980 to 2012 —Con. (In percent) Male Female Country 50 to 54 45 to 49 55 to 59 65 years 60 to 64 60 to 64 65 years 55 to 59 45 to 49 50 to 54 and over years and over years years years years years years years Year —Con. Europe Denmark 93.5 91.4 87.8 60.0 23.2 76.1 67.4 55.8 31.5 6.3 ... 1981 90.2 1993 45.5 10.1 87.7 79.4 63.6 27.1 3.4 93.9 80.6 1 1 89.2 46.7 92.2 2006 85.3 77.0 28.2 20.7 8.4 87.2 83.4 79.5 88.6 52.4 10.2 87.1 83.8 86.6 38.3 4.1 2012 92.2 France 1984 95.0 90.8 70.0 29.9 4.3 61.0 54.1 41.4 18.0 2.1 ... 95.0 1996 16.4 2.3 80.9 71.5 51.7 15.2 2.0 92.6 70.4 90.3 53.4 15.4 1.6 83.2 77.3 94.1 13.4 0.8 2005 62.5 68.3 94.0 25.1 3.1 85.1 81.9 77.0 21.2 1.7 2012 91.1 Germany 1980 96.8 93.3 82.3 44.2 7.4 52.2 47.2 38.7 13.0 3.0 ... 53.7 96.4 34.5 4.9 60.9 79.8 41.1 11.1 1.8 93.2 1988 94.5 90.4 73.9 28.7 4.4 74.7 67.4 50.5 11.3 1.6 1996 91.2 94.3 78.7 82.0 42.3 5.0 83.5 2006 65.6 24.4 2.2 2012 93.9 85.7 58.9 7.1 85.3 81.9 73.3 41.1 3.3 91.6 Greece ... 90.0 81.1 61.7 26.2 28.9 25.8 20.0 13.4 5.0 1981 95.1 37.2 84.2 53.5 14.0 43.9 74.3 29.3 22.0 5.1 1987 98.0 95.2 89.2 75.0 47.8 10.7 1997 39.3 30.7 20.3 3.4 49.9 2006 89.4 74.0 45.2 7.4 64.0 51.3 33.5 21.8 2.1 95.6 56.4 2012 73.0 37.4 4.5 72.1 88.7 40.7 18.8 1.5 93.8 Hungary ... 1980 92.9 86.2 72.2 13.2 4.0 77.5 67.4 18.8 8.7 2.9 2 2 1996 9.2 83.1 70.0 46.1 55.4 6.0 76.1 2.1 4.3 15.5 2 2 61.3 2006 82.5 74.4 19.6 78.9 71.7 44.1 9.4 4.3 1.6 2012 87.6 82.0 68.4 18.6 3.5 84.9 80.0 54.9 11.8 1.3 Italy ... 93.2 85.7 65.1 29.1 1981 36.2 30.2 16.9 8.0 1.5 6.9 1989 95.6 87.5 67.8 35.2 7.9 44.7 34.1 20.2 9.8 2.2 6.0 1996 79.3 58.9 30.6 93.1 49.0 37.1 21.5 8.2 1.8 1.2 2006 94.0 89.0 58.0 28.9 6.1 62.3 54.0 32.8 10.2 74.1 1.4 15.9 6.2 2012 91.6 89.5 48.4 32.7 61.3 66.7 2 2 Norway 90.9 88.7 74.1 . . . . . . . . . . . . . . . . . 1980 94.0 67.5 58.1 76.0 13.0 34.3 39.8 2 2 89.2 64.2 93.9 82.0 1990 62.0 46.5 21.2 83.5 74.5 12.0 2 2 91.7 89.9 84.8 60.6 2000 80.8 71.8 48.4 8.5 13.5 86.0 2 2 90.7 63.0 82.9 87.7 2006 81.5 51.2 84.1 10.6 17.8 71.2 90.1 87.2 83.8 67.5 23.1 84.2 83.5 76.3 58.0 2012 14.6 Poland 81.2 1988 82.4 72.0 53.6 ... 89.6 71.1 50.6 34.3 19.0 32.5 1996 85.1 76.8 55.2 33.4 15.3 79.1 63.1 35.0 19.2 8.5 2006 84.7 51.6 26.8 8.2 77.9 59.8 25.3 12.4 3.3 75.7 73.1 2012 68.5 35.7 7.7 82.5 81.0 46.6 14.2 3.0 86.7 Russia ... 1989 95.8 91.7 79.3 35.4 14.2 93.7 83.8 34.8 20.4 6.4 N 1992 80.5 38.1 13.3 93.9 83.6 43.0 21.0 5.7 N 1999 88.6 85.3 65.2 29.2 6.4 86.8 78.9 33.7 16.0 2.5 88.2 2006 84.8 70.2 39.7 9.4 89.0 80.6 47.0 23.6 4.6 14.1 2012 92.6 88.7 77.8 38.5 52.9 90.6 84.3 24.9 8.9 Sweden ... 89.8 84.4 65.9 8.1 82.9 77.8 66.4 41.4 2.6 1980 92.0 89.5 89.8 63.9 10.6 91.6 85.8 76.8 53.1 3.7 1990 84.1 85.7 90.6 56.2 N 87.2 83.8 79.4 48.2 N 2000 89.9 90.9 89.8 84.9 66.2 N 87.2 85.4 80.0 58.3 N 2006 83.2 94.4 72.8 19.1 89.7 87.8 89.2 63.1 11.3 91.9 2012 Ukraine 1989 95.6 89.9 78.2 32.0 10.9 93.3 86.0 29.5 15.3 4.5 ... 2 2 86.3 76.4 69.7 28.3 1999 84.3 70.1 33.4 16.7 9.8 6.0 6 6 2005 32.2 84.3 79.1 67.6 72.9 24.7 81.1 17.3 22.7 37.6 85.2 78.2 66.7 32.2 20.5 83.2 73.5 34.7 25.9 2012 16.7 United Kingdom 68.5 1981 95.7 91.5 74.6 ... 97.3 63.5 52.0 22.5 3.7 10.7 1993 92.8 88.1 75.7 52.2 7.4 77.9 70.0 54.5 24.7 3.5 4 3 5 2000 N 7.4 N 64.0 68.9 N N N 8.4 N 3 5 4 N 2006 N 9.7 N N 68.6 N N 72.3 11.4 69.0 36.8 6.6 80.2 2012 91.4 88.1 80.0 58.9 12.4 82.1 See notes at end of table. An Aging World: 2015 eau U.S. Census Bur 162

173 Table B-8. Labor Force Participation Rates by Age, Sex, and Country: Selected Years 1980 to 2012 —Con. (In percent) Female Male Country 55 to 59 65 years 45 to 49 45 to 49 60 to 64 55 to 59 60 to 64 65 years 50 to 54 50 to 54 years years years years years years and over and over years years Year Latin America/Caribbean Argentina 92.4 87.6 77.6 51.9 17.9 30.2 25.4 17.6 9.8 ... 1980 3.2 95.0 79.4 56.1 23.5 31.9 27.8 19.8 11.2 3.7 1989 90.6 90.0 46.6 63.2 27.6 53.2 93.6 35.4 22.6 8.9 1995 82.8 62.1 95.3 76.8 28.3 67.2 87.3 55.6 38.7 10.7 2006 92.6 94.6 91.4 86.8 75.7 22.2 67.7 63.4 53.8 33.7 7.5 2012 Brazil ... 85.7 77.9 67.0 32.4 28.1 23.5 18.6 12.6 4.8 1980 91.5 5 4 5 8 8 4 1990 N 49.5 N 94.5 34.5 N N 11.5 82.3 46.0 4 11 12 4 11 12 88.2 N 2000 N 76.8 39.0 49.8 15.5 20.1 4.6 54.6 57.3 92.1 64.9 35.1 65.4 77.6 45.5 30.9 14.1 85.8 2004 91.6 86.1 78.2 62.0 30.0 67.4 58.8 45.5 30.0 11.7 2012 Chile 1982 25.5 90.1 82.8 72.8 61.5 ... 26.0 21.9 16.2 10.1 4.5 1992 94.9 66.6 31.5 39.7 39.3 28.2 19.2 6.3 92.4 82.1 91.3 42.9 69.2 27.4 47.1 95.9 32.4 21.0 6.5 1999 83.4 48.4 95.3 73.2 26.9 51.9 86.1 40.1 25.3 7.7 2006 91.4 93.6 93.8 90.1 80.5 35.0 66.2 61.1 56.0 38.3 12.0 2012 10 5 10 5 Colombia N N ... 58.4 86.0 31.4 N N 1985 N 16.7 N 8 4 11 12 8 4 11 12 1999 25.2 N 69.1 88.2 96.0 43.7 55.4 19.3 N 5.4 49.1 2010 74.5 61.5 69.6 62.3 87.8 35.2 25.0 94.0 96.6 Costa Rica 1984 92.3 88.7 83.0 69.6 38.9 20.9 15.5 11.6 6.9 3.1 ... 8 4 11 12 8 4 11 12 1996 21.1 85.4 44.2 N 94.4 22.2 51.4 9.1 N 2.8 54.3 2006 87.2 71.1 29.1 92.5 42.0 35.0 20.3 6.8 95.7 2012 94.0 92.0 85.8 67.5 26.5 55.0 50.3 39.8 27.3 6.8 Guatemala 6.5 ... 1981 93.2 91.7 90.3 85.8 66.9 12.2 11.6 10.1 9.0 98.0 95.0 13.7 1987 20.6 95.2 23.7 88.5 63.3 31.3 26.6 1998–99 97.7 94.1 87.2 71.4 56.4 46.9 45.1 41.0 28.8 95.1 91.4 2004 92.2 66.7 53.2 44.6 39.7 30.3 23.7 93.8 92.5 51.8 96.2 90.0 66.4 56.0 92.9 44.7 36.3 15.0 2012 96.5 7 7 9 9 Jamaica N 90.5 1988 52.4 ... 73.7 N N 65.4 N 24.9 94.6 9 7 7 9 1998 N N N 75.5 N 95.1 81.6 46.4 18.4 53.5 7 9 7 9 2004 81.8 N 41.4 93.7 72.6 N N 50.1 N 17.3 7 9 9 7 2010 N 80.8 75.9 N N 55.7 N 16.6 90.6 54.8 Mexico 29.1 ... 93.8 91.4 85.6 68.6 95.3 27.5 24.6 24.1 18.6 1980 1988 96.9 91.9 85.5 77.5 58.4 38.2 31.7 24.6 23.2 16.9 41.3 1996 85.6 74.1 52.0 91.9 35.0 31.2 23.8 14.1 95.6 2006 95.4 92.5 88.2 74.0 45.8 50.4 44.0 35.3 28.5 14.7 55.4 2012 91.8 85.4 71.5 42.8 94.9 50.2 41.5 32.8 15.5 Peru 97.1 ... 1972 61.5 95.5 92.8 83.9 19.5 17.9 16.1 13.4 8.5 1981 98.7 94.9 88.5 63.2 26.9 26.0 23.6 23.4 12.5 97.3 94.4 88.3 75.0 34.6 54.4 42.9 38.8 23.9 12.0 1989 83.2 57.2 96.8 72.5 41.1 68.1 85.6 47.5 38.2 19.2 1999 93.3 98.7 94.6 87.0 65.5 28.8 67.0 2006 39.2 34.9 15.3 56.2 2012 94.9 91.0 83.5 56.9 77.8 73.6 65.2 57.8 36.1 97.0 Uruguay ... 94.3 89.4 80.0 51.8 1985 46.4 37.5 25.3 13.3 3.6 16.2 1995 96.4 94.3 89.3 59.3 19.4 64.6 59.5 41.0 23.9 6.7 2006 97.9 91.2 68.8 19.7 75.9 69.4 58.7 39.0 8.4 96.4 73.3 96.3 89.0 65.4 24.5 78.4 2012 67.0 43.1 10.4 94.6 Northern America Canada ... 1981 93.6 90.9 84.4 68.8 17.3 59.6 52.1 41.9 28.3 6.0 76.3 1991 78.3 54.1 14.4 89.5 66.4 49.9 28.1 5.7 93.1 2001 91.1 86.4 72.2 46.5 9.4 79.8 72.7 53.3 27.4 3.4 12.1 2006 87.8 76.1 53.3 90.8 82.6 78.1 62.3 37.1 5.2 45.7 69.4 8.8 2012 89.9 87.8 78.9 58.0 17.1 84.4 80.9 See notes at end of table. 163 An Aging World: 2015 U.S. Census Bureau

174 Table B-8. Labor Force Participation Rates by Age, Sex, and Country: Selected Years 1980 to 2012 —Con. (In percent) Male Female Country 55 to 59 60 to 64 50 to 54 45 to 49 45 to 49 50 to 54 55 to 59 60 to 64 65 years 65 years years and over years years years years years years and over years Year —Con. Northern America United States ... 88.5 80.6 60.4 19.3 92.0 56.3 48.4 34.0 8.2 1980 61.5 92.2 88.4 79.0 54.8 15.8 75.4 67.8 55.7 35.1 8.6 1991 2000 90.1 86.8 77.1 54.8 17.5 79.1 74.1 61.2 40.1 9.4 7 7 2006 N 57.5 19.7 85.7 76.3 N 64.7 45.4 10.7 64.7 2012 88.1 84.1 78.0 60.5 23.6 75.6 73.7 67.3 50.4 14.4 Oceania Australia ... 1981 92.5 89.4 81.3 53.1 12.3 56.5 46.3 32.8 15.5 4.9 7 7 1991 89.6 N 73.8 50.0 8.9 2.5 62.8 N 36.0 15.2 1999 85.1 3.1 18.3 89.5 44.6 72.5 46.7 9.6 73.8 65.0 73.4 2006 56.4 12.1 78.3 75.7 57.9 33.5 4.3 86.1 89.2 78.5 86.7 80.0 62.6 16.8 2012 76.3 65.7 44.5 7.8 89.2 New Zealand 10.9 ... 95.8 94.1 87.5 45.7 1981 52.5 43.7 30.9 11.7 1.9 2.9 1992 94.2 89.5 80.0 33.5 8.8 79.7 65.7 49.9 15.7 79.9 73.6 1999 90.7 88.4 81.2 57.4 10.4 3.9 32.5 60.1 2006 92.6 87.2 73.1 16.8 81.9 80.0 71.7 50.0 8.0 91.6 82.8 2012 88.2 77.6 25.5 82.3 90.9 77.4 64.1 15.0 91.5 N Not available. 1 Refers to ages 65 to 66 years. 2 Refers to ages 65 to 74 years. 3 Refers to ages 50 to 64 years. 4 Refers to ages 50 to 59 years. 5 Refers to ages 60 years and over. 6 Refers to ages 65 to 70 years. 7 Refers to ages 45 to 54 years. 8 Refers to ages 40 to 49 years. 9 Refers to ages 55 to 64 years. 10 Refers to ages 45 to 59 years. 11 Refers to ages 60 to 69 years. 12 Refers to ages 70 years and over. Notes: For some countries in this table, data are derived from labor force surveys as well as population censuses. Labor force surveys are more focused on economic activity than are general census enumerations and, therefore, may yield more comprehensive information on various aspects of economic activity. The user should recognize that temporal differences in labor force participation rates within a country may, in part, reflect different modes of data collection. Czech Republic: Data prior to 1991 refer to the former Czechoslovakia. Germany: Data prior to 1996 refer to the former West Germany. United Kingdom: Data for 2000 and 2006 are averages of reported quarterly rates. Sources: U.S. Census Bureau, Population Division data files; various issues of the International Labour Office Yearbook of Labour Statistics; and the International Labour Office electronic data base accessible at . An Aging World: 2015 U.S. Census Bureau 164

175 APPENDIX C. Sources and Limitations of the Data This report includes data compiled updated estimates and projections making assumptions about future by the International Programs area for countries as new data have change, and final projection of the in the Population Division of the become available. Estimates and population for each country. The Census Bureau, from publications projections for countries, as well as Census Bureau begins the process and electronic files of national for regions and the world, are made by collecting demographic data statistical offices, various agencies available to the public through the from censuses, surveys, vital regis- of the United Nations, and other Census Bureau’s International Data tration, and administrative records international organizations (e.g., Base (IDB), located at from a variety of sources. Available the Organisation for Economic . attention to internal and temporal European Union, the World Health consistency. The Census Bureau’s IDB estimates Organization, and the International and projections have several Estimation and projection proce- Labour Organization). It also distinguishing features. For coun- dures make use of a variety of includes cross-national informa- tries and areas recognized by the demographic techniques and tion from sources such as the U.S. Department of State and which incorporate assumptions formed Global Burden of Disease Project, have populations of 5,000 or more, by consulting the social science the Survey of Health, Ageing and population size and components and health science literature. In Retirement in Europe, the Study on of change are provided for each addition to using demographic Global Ageing and Adult Health, calendar year beyond the initial or data, Census Bureau demographers and other university-based research base year, through 2050. Within consider information on public projects. this time series, sex ratios, popula- health efforts, sociopolitical circum- The majority of demographic tion, and mortality measures are stances, and historical events such projections in Chapter 2, Chapter developed for single-year ages as natural disasters and civil con- 3, and Appendix B come from through age 100-plus. As a result flict in preparing the assumptions the International Data Base (IDB), of single-year age and calendar- feeding into population projections. maintained and updated by Census year accounting, IDB data capture Regional and world populations are Bureau’s Population Division. The the timing and demographic impact obtained by projecting each coun- Census Bureau has been preparing of important events such as wars, try’s population separately and then estimates and projections of the famine, and natural disasters, with combining the results to derive populations of foreign countries a precision exceeding that of other aggregated totals. For more details since the 1960s. In the 1980s, the online resources for international on methodology, see International Census Bureau released its first demographic data. Data Base Population Estimates and comprehensive set of estimates and Projections Methodology located The estimation and projection pro- projections for over 200 countries at . 165 An Aging World: 2015 U.S. Census Bureau

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