A rapidly aging population poses serious challenges for many countries around the world, particularly in Asia, home to the most populous countries. China and India account for nearly 36% of the world’s population, and are expected to face social and economic complications from demographic change in the next decades.

A special issue of the Journal of the Economics of Ageing explores these trends in a comparative perspective, “The Economic Implications of Population Ageing in China and India” (December 2014), co-edited by David Bloom, a professor at Harvard University’s School of Public Health, and Karen Eggleston, a Center Fellow at the Shorenstein Asia-Pacific Research Center.

“Population ageing represents uncharted waters for China and India,” Bloom and Eggleston write in their coauthored introduction.

The special issue is a collection of 10 articles that examine the economic benefits and potential dilemmas arising from decreased fertility and increased life expectancy, two trends that will impact the development and future trajectories of China and India at the micro- and macroeconomic levels.

Dropping or continued low birth rates imply fewer young people to refresh the labor market. But will this cause the workforce to shrink to an unsustainable level? Demand will increase for health care, long term care, and other social services that support the elderly. What must the government do to ensure adequate access to care?

Empirical data and commentary presented in the special issue seek to inform stakeholders about emerging patterns, and to provide insight on how to best address related policy challenges going forward.

“By adopting responsive behaviors and consultative institutions that address the challenges of population ageing in ways that are appropriate to their unique circumstances, China and India could reap the full economic and social benefits of longer, healthier lives,” they write.

The special issue includes an introduction by Bloom and Eggleston, a feature interview with Richard Suzman, and additional analysis by noted global health experts following each article. The titles and authors of the 10 original research articles are listed below:

• Intergenerational co-residence and schooling (Anjini Kochar)
• Regional disparities in adult height, educational attainment, and late-life cognition: Findings from the Longitudinal Aging Study in India (LASI) (Jinkook Lee, James P. Smith)
• Healthy aging in China (James P. Smith, John Strauss, Yaohui Zhao)
• Gender differences in cognition in China and reasons for change over time: Evidence from CHARLS (Xiaoyan Lei, James P. Smith, Xiaoting Sun, Yaohui Zhao)
• Reprint of: Health outcomes and socio-economic status among the mid-aged and elderly in China: Evidence from the CHARLS national baseline data (Xiaoyan Lei, Xiaoting Sun, John Strauss, Yaohui Zhao, Gonghuan Yang, Perry Hu, Yisong Hu, Xiangjun Yin)
• Should China introduce a social pension? (Bei Lu, Wenjiong He, John Piggott)
• China’s age of abundance: When might it run out? (Yong Cai, Feng Wang, Ding Li, Xiwei Wu, Ke Shen)
• The macroeconomic impact of non-communicable diseases in China and India: Estimates, projections, and comparisons (David E. Bloom, Elizabeth T. Cafiero-Fonseca, Mark E. McGovern, Klaus Prettner, Anderson Stanciole, Jonathan Weiss, Samuel Bakkila, Larry Rosenberg)
• Economic development and gender inequality in cognition: A comparison of China and India, and of SAGE and the HRS sister studies (David Weir, Margaret Lay, Kenneth Langa)
• Comparing the relationship between stature and later life health in six low and middle income countries (Mark E. McGovern)

The special issue of the Journal of the Economics of Ageing, vol. 4, pages 1-154 (December 2014) is available through Elsevier’s online platform ScienceDirect.

Dr. Marcella Alsan argues that the tsetse fly contributed to Africa's historically low population density.

China’s State Council has put forth draft legislation that would ban smoking in public spaces, part of the government’s larger advocacy efforts to help curb tobacco use nationwide. Matthew Kohrman, a professor of anthropology at Stanford University, said it’s a step forward but the ban’s long-term success would depend on local enforcement.

Despite popular belief, global cigarette production has tripled worldwide since the 1960s. Leading the surge has been China.

“China has become the world’s cigarette superpower,” said Kohrman, in an interview on National Public Radio’s program, Marketplace.

Moreover, local governments in China have become dependent on tax revenues generated from tobacco sales, thus reinforcing the cigarette’s ubiquity and ease of access.

China has implemented smoking bans in the past, but with varied success. Now rising healthcare costs caused by tobacco-related diseases are creating urgency for new regulations.

“Whether or not these new regulations will be enforced will, in the end, come down to local politics,” he said.

Matthew Kohrman is part of the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, and leads the project, Cigarette Citadels, a peer-sourced mapping project that compiles more than 480 cigarette factories globally.

The full audioclip is available on the Marketplace website.

A middle class is emerging in China, and simultaneously, its population is rapidly aging. These two phenomena are impacting the country’s traditional consumer habits, including spending on healthcare. Experts say private-sector services are one important part of the future of China’s healthcare system, and perhaps also a sign of what’s to come for other countries in the region. Entrepreneurs can provide innovative services that cater widely to consumers and support a shift toward integrated care for health promotion and long-term management of chronic disease, also supplementing resources available in traditional public facilities.

Three experts visited the Walter H. Shorenstein Asia-Pacific Research Center and shared perspectives on those trends at the panel discussion, “Healthcare Entrepreneurs in East Asia: Innovations in Primary Care and Beyond,” hosted by the Asia Health Policy Program.

Historically, healthcare services in China have been almost entirely government-run. A patient would go to a public clinic, stand in a queue, and receive treatment within a few hours – being referred elsewhere if additional treatment was required.

Now, the private sector is growing, based on the promise of improved care and an enhanced experience, both removing the waiting line and ushering in new technologies. The government has also issued several policies encouraging “social capital” investment in health and fitness services.

The private sector for preventative care services now holds around fifteen percent of the entire marketplace in China, and “is expected to get much bigger over the next five years,” said Lee Ligang Zhang, the founding chairman and chief executive officer of iKang, a healthcare group based in Beijing.

Zhang oversees the company’s operation of 50 self-owned healthcare centers and an extended network of 300 affiliates. iKang is one of many groups catering to a growing consumer base of corporate workers and senior managers seeking care outside of the public system.

Comparative view

Increased development of premium healthcare facilities is not only emerging in China, but also in neighboring Taiwan. Since 1995, Taiwan implemented a national health insurance system, and has been lauded for its success in service provision.

Taiwan transitioned its healthcare market to universal coverage. Under this system, a patient can essentially “shop around” and select where to go for services, most of which are covered under the country’s insurance collective system at public or private providers.

“On average, every Taiwanese goes to see a doctor 14 times a year, compared to five times a year in the United States, and two times [a year] in China,” said Dr. Fred Hun-Jean Yang, a physician and chairman of MissionCare, Inc.

Such numbers reflect the higher availability of services compared to China, he said. Even as a small island, Taiwan has over 15,000 clinics and the price for services is generally affordable for the average citizen. Despite this availability of public and private services, Taiwan’s newer healthcare entrepreneurs seek to fill a market demand shaped by similar factors as in China. Yang says technology and the efficiency of the private sector healthcare system is attracting new consumers.

Missioncare is headquartered in northern Taiwan’s Taoyuan City and consists of four community hospitals with a larger network of clinics across the country as well as coordinated long-term care services for the elderly and those with chronic disease. The group has already expanded into China, and plans to integrate healthcare innovations, such as wearable monitoring and mobile payment.

Patient-centric service

Chinese citizens, particularly those with greater expendable income, are more willing to pay out-of-pocket for an improved patient experience, the panelists said.

“The consumer psyche is important,” said Dr. Wei Siang Yu, the founder of the Borderless Healthcare Group (BHG), a group of companies based in Singapore that focuses largely on health telecommunications.

One perspective is that consumers desire a “high-end” environment made possible by tailored design aesthetics and effective branding. Guided by this trend, Yu, a business executive and physician by training, started the “smart cities, smart homes” initiative at BHG.

BHG is now launching an incubator model in Shanghai, which combines intelligent design aesthetics with patient care, and is planning to localize such centers across China. The model is referred to as an “experience center,” rather than a hospital or clinic, and healthcare services – examinations, operations and value-added activities like wellness and education activities – are all centralized in one location.

Looking ahead, Yu said healthcare is likely to move even further away from the traditional hospital setting, and more toward experiential and home-based care models.

In a recent speech, Stanford professor Rosamond Naylor examined the wide range of challenges contributing to global food insecurity, which Naylor defined as a lack of plentiful, nutritious and affordable food. Naylor's lecture, titled "Feeding the World in the 21st Century," was part of the quarterly Earth Matters series sponsored by Stanford Continuing Studies and the Stanford School of Earth Sciences. Naylor, a professor of Environmental Earth System Science and director of the Center on Food Security and the Environment at Stanford, is also a professor (by courtesy) of Economics, and the William Wrigley Senior Fellow at the Freeman Spogli Institute for International Studies and the Stanford Woods Institute for the Environment.

"One billion people go to bed day in and day out with chronic hunger," said Naylor. The problem of food insecurity, she explained, goes far beyond food supply. "We produce enough calories, just with cereal crops alone, to feed everyone on the planet," she said. Rather, food insecurity arises from a complex and interactive set of factors including poverty, malnutrition, disease, conflict, poor governance and volatile prices. Food supply depends on limited natural resources including water and energy, and food accessibility depends on government policies about land rights, biofuels, and food subsidies. Often, said Naylor, food policies in one country can impact food security in other parts of the world. Solutions to global hunger must account for this complexity, and for the "evolving" nature of food security.

As an example of this evolution, Naylor pointed to the success of China and India in reducing hunger rates from 70 percent to 15 percent within a single generation. Economic growth was key, as was the "Green Revolution," a series of advances in plant breeding, irrigation and agricultural technology that led to a doubling of global cereal crop production between 1970 and 2010. But Naylor warned that the success of the Green Revolution can lead to complacency about present-day food security challenges. China, for example, sharply reduced hunger as it underwent rapid economic growth, but now faces what Naylor described as a "second food security challenge" of micronutrient deficiency. Anemia, which is caused by a lack of dietary iron and which Naylor said is common in many rural areas of China, can permanently damage children's cognitive development and school performance, and eventually impede a country’s economic growth.

Hunger knows no boundaries

Although hunger is more prevalent in the developing world, food insecurity knows no geographic boundaries, said Naylor. Every country, including wealthy economies like the United States, struggles with problems of food availability, access, and nutrition. "Rather than think of this as 'their problem' that we don't need to deal with, really it's our problem too," Naylor said.

She pointed out that one in five children in the United States is chronically hungry, and 50 million Americans receive government food assistance. Many more millions go to soup kitchens every night, she added. "We are in a precarious position with our own food security, with big implications for public health and educational attainment," Naylor said. A major paradox of the United States' food security challenge is that hunger increasingly coexists with obesity. For the poorest Americans, cheap food offers abundant calories but low nutritional value. To improve the health and food security of millions of Americans, "linking policy in a way that can enhance the incomes of the poorest is really important, and it's the hard part,” she said.” It's not easy to fix the inequality issue."

Success stories

When asked whether there were any "easy" decisions that the global community can agree to, Naylor responded, "What we need to do for a lot of these issues is pretty clear, but how we get after it is not always agreed upon." She added, "But I think we've seen quite a few success stories," including the growing research on climate resilient crops, new scientific tools such as plant genetics, improved modeling techniques for water and irrigation systems, and better knowledge about how to use fertilizer more efficiently. She also said that the growing body of agriculture-focused climate research was encouraging, and that Stanford is a leader on this front.

Naylor is the editor and co-author of The Evolving Sphere of Food Security, a new book from Oxford University Press. The book features a team of 19 faculty authors from 5 Stanford schools including Earth science, economics, law, engineering, medicine, political science, international relations, and biology. The all-Stanford lineup was intentional, Naylor said, because the university is committed to interdisciplinary research that addresses complex global issues like food security, and because "agriculture is incredibly dominated by policy, and Stanford has a long history of dealing with some of these policy elements. This is the glue that enables us to answer really challenging questions."