Promoting Active Ageing in Southeast Asia

This chapter emphasises the need to strengthen health and social policies in order to drastically improve the prospects of active and healthy ageing in ASEAN countries. The first section highlights the importance of improving access to good-quality care and of focusing on the prevention of bad health at older ages. ASEAN countries spend a small share of GDP on healthcare even when we take into account their economic development level. Yet, ASEAN countries have made strong progress towards universal health coverage over the past decades, even though coverage trails behind for some social groups. The second section analyses current pension systems in ASEAN countries. Low coverage of old-age pensions is one serious issue triggered by the recent development of pension insurance and large labour-market informality. In addition, old-age safety-net benefits have low levels, generating high risks of income poverty. Given their current design, most pay-as-you-go pension systems in ASEAN countries are not financially sustainable given ageing prospects. The third section digs into facilitators and barriers to ageing in place and older people’s ability to move around. Indeed, older people’s capacity to remain active in society depends among other factors on their living arrangements and their capacity to get around. The last section analyses gender inequalities in ASEAN countries and zooms in on the unbalanced care responsibilities faced by women. It highlights that gender discrimination in Southeast Asia is very prominent in the family sphere, with legislation playing a role in some countries. Drastically reducing gender inequality will require a societal transformation of both women’s and men’s views on which behaviours and types of paid or unpaid work are appropriate for men and women to execute.

The Key findings are the following.

Improving access to good-quality healthcare and preventing bad health

• Total health expenditure is low in ASEAN countries. In particular, public spending on health is low in ASEAN countries compared to other countries with similar levels of economic development, in particular in Brunei Darussalam, Lao PDR, Malaysia and Singapore. On average, total health spending is 4.7% of GDP in ASEAN countries, half the OECD average, ranging from below 3% in Brunei Darussalam and Lao PDR to above 7% in Cambodia.

• ASEAN countries have successfully expanded public health insurance coverage for the large majority of the population, except for Cambodia and Myanmar. However, health expenditures remain an important expense for many older people and the low availability of healthcare services impedes healthcare use, especially in rural areas.

• ASEAN countries have made strong progress making basic health services more accessible since 2000 especially as a result of tackling infectious diseases, although since 2015 progress has slowed substantially.

• On average, ASEAN and OECD countries spend 0.5% of GDP on preventive care, ranging from around 0.3% in Lao PDR and Thailand to around 0.8% in Indonesia and Malaysia. The level of spending on preventive care falls short to effectively improve health in later life and reduce health inequalities, both in ASEAN and OECD countries.

• Non-communicable diseases connected to unhealthy lifestyles have become a more prominent driver of mortality, long-term illnesses and healthcare spending. The share of the population using tobacco is still at least double the global target of 19% in Indonesia and Myanmar. Alcohol consumption has increased strongly in Cambodia, Lao PDR and Viet Nam over the last decades. Obesity is on the rise in all ASEAN countries, affecting 12% of adults in ASEAN countries on average in 2022 compared to only 5% two decades earlier.

Improving pension systems

• The number of workers accruing pension entitlements in ASEAN countries is very low. The proportion of the labour force covered by mandatory pensions ranges from 4% in Myanmar, 10% in Lao PDR and 16% in Indonesia to around 60% in Brunei Darussalam, Malaysia and Singapore and 65% in Thailand. In almost all ASEAN countries, self-employed workers are not mandatorily covered by the pension system but rather rely on voluntary contributions.

• Most retirees are not getting a pension in ASEAN countries. In both Cambodia and Lao PDR, under 7% of those older than the retirement age receive a pension. Pension coverage is also low at 15% in Indonesia and Myanmar. Only Brunei Darussalam and Thailand have high levels of retirees receiving a benefit, at 100% and 89%, respectively, as they both have residence‑based basic pensions.

• First-tier benefit levels are very low in most ASEAN countries. Only Brunei Darussalam and Malaysia have either a basic pension or a targeted safety‑net benefit above 10% of gross average earnings. All of the others have targeted safety-net benefits around 5‑7% of average earnings with the exception of Thailand, which is only at 4%, while there are no old-age safety-net benefits in both Cambodia and Lao PDR.

• Workers in the public sector often have a different earnings-related pension scheme than in the private sector. Only Brunei Darussalam, Singapore and Viet Nam have the same earnings-related pension for both sectors; Indonesia has the same DB scheme for all employees but those in the public sector have a higher FDC contribution rate, while Cambodia has a higher accrual rate for public‑sector workers.

• In many ASEAN countries, mandatory pension contribution rates are low, well below those in the majority of OECD countries. Across ASEAN countries, the total contribution rate is only 12.9% on average, while the OECD average is 18.2%.

• On average across ASEAN countries, the normal retirement age for male private-sector workers who retired in 2022 was 59.2 years, with limited legislated increases, compared to an OECD average of 64.4 years, ranging from a low of 55 years in Malaysia and Thailand to a high of 63 years in Singapore with half the countries at age 60. The current gap between the average normal retirement age in ASEAN and OECD countries largely reflects current differences in old-age life expectancy.

• Given population ageing prospects and the current levels of pension parameters, pay-as-you-go pension systems are financially unsustainable in ASEAN countries, especially in Lao PDR, Indonesia and Thailand.

Facilitating ageing in place and the mobility of older people

• ASEAN countries have high home ownership rates, providing a stable living environment that facilitates the development of durable social connections in the community. The home‑ownership rate ranges between 77% in Thailand (except the Philippines at 57%) and 89% in Singapore, compared with 71% in the OECD on average.

• Multigenerational households are very common in ASEAN countries as on average 46% of people aged 65+ live in a household comprising at least three generations, ranging from around 30% in Thailand to over 60% in Lao PDR, and another 5‑10% live in households of grandparents and their grandchildren, without the generation in between (“skip-generation”). Cohabitating with grandchildren provides opportunities for social interaction and for older people to contribute to the household’s welfare through grandparenting, but it may also limit social interactions outside the household.

• Several ASEAN countries have implemented policies to provide opportunities for older people living in the community to participate in social activities. Brunei Darussalam, Malaysia, the Philippines, Singapore, Thailand and Viet Nam have community centres for older people that often combine providing social activities with some care‑related functions.

• Public transport is a key component of designing age‑friendly environments and of active ageing as older people in ASEAN countries are more likely to partake in activities if there is an accessible bus station in their neighbourhood.

• Reduced fares are a common initiative to increase older people’s use of public transport services. In Brunei Darussalam, Cambodia, Indonesia, Malaysia, the Philippines, Singapore, Thailand and Viet Nam, older people benefit from discounts on public-transport fares, often travelling at half the regular price.

Reducing gender inequalities and formalising care

• Gender discrimination in Southeast Asia is very prominent in the family sphere. Women fare far worse in ASEAN countries than in the OECD in terms of discriminative laws in the family sphere. Gender discrimination in family and inheritance laws is very high in Brunei Darussalam, Indonesia and Malaysia, and also but to a lesser extent in Cambodia and Lao PDR.

• In all ASEAN member states except Cambodia, Lao PDR and Viet Nam, the different treatment of men and women is formalised through personal status laws that apply only to particular religious, ethnic or cultural groups. All countries but Brunei Darussalam have passed policy frameworks or national action plans to reduce gender inequalities, in particular since 2019.

• There are strong legal and cultural expectations for families to provide care for older relatives. In all ASEAN countries, the law stipulates that the family has a certain responsibility in providing care for relatives. Except in Singapore, formal long-term care services for older people are underdeveloped in ASEAN countries, which means that families, and in particular women, often have to step in to provide long-term care.

• Unpaid care and domestic work is distributed very unequally between men and women in ASEAN countries. Women account for 91% of unpaid work in Cambodia and 76% in Malaysia and Thailand. Lao PDR has the least unequal distribution of unpaid work, with women performing 57% of unpaid work.

Preventive care and access to good-quality healthcare are essential to improve health at older ages, as is adequate financing to realise these goals. Good health is an important factor for active ageing as illness and disability can limit a person’s well-being and their capacity to participate actively not only in the labour market but also in other spheres of life. While the focus here is on improving health as a way to boost active ageing, the relationship between health and participation in various activities including employment is not a unidirectional one. Not only is bad health a barrier to participation, but there is widespread evidence that social isolation is one driver of deterioration of health among older adults (Nicholson, 2012[1]). Social participation affects health in a number of ways as other persons can encourage seeking medical attention, adhering to treatment or maintaining a healthier, more active lifestyle. Reduced social participation furthermore increases the risk of depression and cognitive decline.

Total health expenditure is low in ASEAN countries (Figure 3.1). On average, they spend 4.7% of GDP on health, half the OECD average, ranging from below 3% in Brunei Darussalam and Lao PDR to above 7% in Cambodia (2021 data). In Lao PDR, total healthcare expenditures have declined as share of GDP as neither public nor private healthcare expenditure have kept up with GDP growth since 2008, when the country spent around 4% of GDP on healthcare (Sorensen et al., 2017[2]). This low level of expenditure narrows the possibilities for a country to improve overall health outcomes.1 Moreover, in ASEAN countries on average, out-of-pocket health expenditure is at 1.6% of GDP, which is comparable to the OECD average. Medicines are the main source of out-of-pocket spending in the region (WHO / World Bank, 2023[3]). While out-of-pocket expenditure even reaches 4% of GDP in Cambodia and Myanmar, it is below 0.5% of GDP in Brunei Darussalam and Thailand as public healthcare is free of charge. Out-of-pocket expenditures in the Philippines remain high, although the country has managed to reduce them over the last decade through expanding coverage of the national health insurance scheme “PhilHealth” (see below).2

Hence, the large difference between ASEAN and OECD countries in terms of healthcare spending is the result of low financing from other sources than out-of-pocket expenditures, including from taxes and healthcare contributions. Moreover, government spending on health is low in ASEAN countries compared to other countries with similar levels of economic development: all ASEAN countries fall below what is consistent with levels of GDP-per-capita based on cross-country comparison (Figure 3.2). In particular, the governments of Brunei Darussalam, Lao PDR, Malaysia and Singapore spend little on health compared to countries with similar economic development levels – see Colombia, Timor-Leste and Japan in the Figure. Furthermore, 35% of total health spending in 2021 was financed from social health insurance in the OECD on average, with employers, employees and the state contributing roughly equally to the health insurance budget, compared to 8% of total spending on average across ASEAN countries (WHO, 2024[4]). The health insurance fund in Indonesia is contribution-based, but the state pays the contributions for low-income people who represent 59% of all insured in 2021 (Asante et al., 2023[5]) – topped up with tax revenues, including from tobacco products, and financial support from international development agencies (Agustina et al., 2019[6]). In the Philippines, healthcare contributions of older people are subsidised by the state from taxes on tobacco and alcohol consumption (Department of Health of the Philippines, 2018[7]).

In addition to difficulties in collecting taxes or social contributions in countries with large informal economies, the political decision on what to do with the resources collected plays a role in low public healthcare expenditure. Even as percentage of total government spending, health expenditures are low in ASEAN countries. Government spending on health made up around 10% of total government spending on average in ASEAN countries, ranging from around 4% in Lao PDR and Myanmar to 21% in Singapore, compared to 16% in the OECD on average in 2021. Relative to peers in terms of economic development, Brunei Darussalam, Lao PDR, Malaysia and Myanmar spend a significantly lower share of the total government budget on health, and to a lesser extent this is also the case for Cambodia, the Philippines and Viet Nam. Indonesia, Singapore and Thailand, in contrast, spend a somewhat larger share of their government budgets on health than other countries with a similar per-capita GDP.

To ensure healthy ageing in the future, health systems should be financially sustainable. Maintaining universal health coverage may create financial pressure as societies age, as an increasing share of the population will pay limited healthcare contributions and will have higher healthcare expenditures. Projections from Thailand, for instance, show that rapid population ageing in combination with widespread undeclared work will put universal health coverage under strong financial pressure. As the population ages, health expenditures will rise and the tax base from which public health spending is financed will shrink (Hsu, Huang and Yupho, 2015[8]). To meet increasing costs, the healthcare budget can be increased through expanding the contribution base, raising health-insurance contribution rates and/or allocating more resources from general tax revenues. In the case of Thailand, for instance, relying on tax-rate increases alone to cover the projected rise in public health expenditures is unrealistic as by one estimate, this would require that labour income tax increases by at least 11 percentage point by 2050 or the consumption tax rate by at least 8 percentage points, compared to their 2005 levels (Hsu, Huang and Yupho, 2015[8]).

Expanding the contribution base through mandatory coverage and subsequently increasing contribution rates is an effective way to increase the financial resources of the healthcare system. The deficit the Indonesian national health insurance scheme has faced each year since its inception in 2014 has diminished in recent years. After contribution rates were increased in 2016, the deficit in the health insurance scheme declined from 15% of total contributions in its first year (Hidayat et al., 2015[9]) to 3% three years later (Health Policy Plus, 2018[10]). Self-enrolment proved to be a financially unsustainable way to expand healthcare coverage as almost one‑quarter of self-enrolled people only enrolled when they incurred medical expenses, and about one‑quarter do not regularly pay contributions, contributing to expenditures being more than four times higher than revenues for self-enrolled persons (Health Policy Plus, 2018[10]). However, increasing contributions may reduce the coverage of undeclared workers: the 2016 increase in contribution rates did reduce the share of self-enrolled people paying regular contributions (Nurhasana et al., 2022[11]). With the passing of a new health law in 2023, healthcare coverage was in principle expanded to the entire population (Wijayanti, 2023[12]). For about half the population, health insurance contributions are paid fully by the central or regional government in the form of a flat-rate payment.3 The expansion of national health insurance has benefited poor people as their out-of-pocket expenditure was significantly reduced (Saputri and Murniati, 2023[13]).

Given large informality, a tax-financed healthcare scheme is likely to be more effective at reaching universal healthcare coverage than a scheme financed from social-insurance contributions. High prevalence of undeclared work is a significant obstacle to financing healthcare through social health insurance based on employer and employee contributions (Lim et al., 2023[14]). Social health insurance in ASEAN countries was often developed for formal employees, followed in most countries by a separate tax-financed scheme for poor and older people. This has resulted in the “missing middle” problem: a lower middleclass of undeclared workers who are not covered through their employment and not poor enough to qualify for tax-financed healthcare (Kaiser et al., 2023[15]). Therefore, Thailand opted to introduce a universal tax-financed scheme, which also covers undeclared workers, alongside existing schemes for private‑sector employees and civil servants (see below). Tax financing was chosen as a large share of the population could not afford health insurance premiums and undeclared work made it difficult to identify people who should contribute and how much. Under the universal scheme, known as the “30‑baht policy”, the patient’s co-payment for any medical service is limited to THB 30, or less than one US dollar; the co-payment has been eliminated for treatments in public healthcare facilities. The scheme drastically reduced the share of out-of-pocket expenditures in total health spending (Hsu, Huang and Yupho, 2015[8]). A healthcare system consisting of a tax-financed basic care package, supplemented with mandatory health insurance providing access to a wider set of healthcare services could encourage paying health insurance contributions, in particular if health insurance contributions are progressive to limit disincentives for low-income workers to formalise employment (OECD, 2024[16]).

Universal health coverage has been set as a priority in Southeast Asia by the WHO since 2014, and enshrined in the United Nations’ Sustainable Development Goals (Dhillon et al., 2023[17]).4 The objective is that people should have access to basic care provision close to home and should be able to access more advanced care if needed without facing very high expenditures.

Following the global trend, ASEAN countries have made strong progress towards universal health coverage since 2000. On the WHO’s measure of coverage of “essential” health services (the UHC Service Coverage Index),5 ASEAN countries on average improved from 38 to 67 points on a 100‑point scale between 2000 and 2021, with big improvements in particular in Cambodia, Thailand and Viet Nam (Figure 3.3). Over the same period, the OECD average increased from 70 to 83 points.

Tackling infectious diseases has been one main achievement towards universal health coverage in ASEAN countries. Three fifths of the progress ASEAN countries made on the index since 2000 are due to improvements in relation to infectious diseases (consisting of access to basic sanitation, coverage of tuberculosis treatment and HIV therapy and insecticide‑treated nets in areas with high malaria risk). One small note of caution: since 2015 progress has slowed substantially (WHO / World Bank, 2023[3]).6 Between 2015 and 2021, Viet Nam’s score remained stagnant, and Myanmar’s even declined.

Tackling non-communicable diseases (access to hypertension treatment, prevalence of diabetes and tobacco use) has also improved to a certain extent, accounting for about one‑fifth of the region’s progress on the overall index. There is still a wide margin for improvement in this area, and in particular in Indonesia and Myanmar.

The remaining one‑fifth of the progress is in equal parts due to improvements in the capacity of healthcare services (hospital bed density, health worker density and overall health system capacity as measured by the International Health Regulations core capacity index) and in reproductive, maternal and child health. Nonetheless, Thailand and, to a lesser extent, Indonesia and Myanmar, have made significant progress in terms of service capacity and access over the last two decades, while Cambodia and Lao PDR trail behind their regional counterparts.

To realise universal health coverage, the healthcare system should have the capacity to provide the full range of “essential” healthcare services in a way that they are both affordable and accessible for the full population. Social health insurance is an important determinant of affordable care. When designing social health insurance, policy makers have to make decisions in three key areas: eligibility (who is covered?), benefits (what is covered?) and financing (how much is covered by whom?) (Fan, Sharma and Hou, 2023[19]).

Countries in the region have successfully devised different strategies to move towards universal health coverage. To extend coverage to undeclared workers, Thailand established universal healthcare coverage in 2002 through introducing a third scheme alongside existing schemes for civil servants and formal employees as it proved too difficult to harmonise these schemes. This third scheme replaced targeted schemes that had provided healthcare to poor people (Lim et al., 2023[14]). As a result, healthcare coverage increased from around 70% of inhabitants in 2001 to 95% two years later and virtually the full population a decade after the introduction (Hsu, Huang and Yupho, 2015[8]; Nonkhuntod and Yu, 2018[20]). Indonesia integrated pre‑existing schemes for civil servants, military personnel, employees and poor people into a single health insurance fund in 2014, and eliminated the possibility for employers to opt out from social security. As a result, healthcare coverage expanded from 46% of the population in 2013 to 95% in 2023.7 Coverage was expanded to the full population following the passing of a new health law in 2023 (Wijayanti, 2023[12]). Lao PDR launched a national health insurance scheme in 2016 and integrated five pre‑existing schemes into it over the subsequent three years. Health coverage hence increased from 28% of the population in 2015 to 94% in 2017 and has remained stable since (WHO, 2023[21]). The country aims to achieve universal coverage by 2025 (Lao People’s Democratic Republic, 2021[22]). In the Philippines, PhilHealth was established in 1995 to provide social health insurance to formal employees and with the possibility for anyone else to register voluntarily; it was expanded in 2013 to also include poor, sick, disabled and older people, as well as women and children. As a result, coverage was increased from 84% of the population before the reform to 91% three years later (Department of Health of the Philippines, 2018[7]). With the passing of the Universal Health Care Act in 2018, coverage was legally extended to the entire population.

Experiences in Indonesia and the Philippines illustrate that relying on self-enrolment of certain groups is ineffective to sustainably achieve broad health coverage. While the possibility to opt in at a time of medical need and drop out again once treatment has terminated does give people access to healthcare services, this undermines the financial sustainability of health insurance schemes and ultimately limits the funds available to sustain broad service provision. The Indonesian health coverage rate increased significantly after the possibility for employers to opt out was eliminated. Voluntary coverage in the Philippines failed to provide protection to a significant part of the population, including poor and older people. Both Indonesia and the Philippines only achieved full health insurance coverage after legislating an extension to the full population. Experimental evidence from Indonesia furthermore indicates that enrolment subsidies, even those that are limited in time, are an effective way to increase enrolment and reduce the likelihood that people only enrol when health needs emerge. While providing assistance to people to register also increased registration, registration did not increase if people merely received information on health insurance (Banerjee et al., 2021[23]).

Cambodia and Myanmar are still far from realising full public health insurance coverage. In Cambodia, around 30% of people were estimated to be covered by health insurance in 2019, either by providing insurance‑based coverage to civil servants and employees, or by targeting the poorest and funded from taxes (Kolesar et al., 2020[24]). Qualification for the targeted scheme is determined through IDPoor, a standardised questionnaire providing an overview of household assets and proxy measures of poverty such as educational level.8 The government is committed to further increase coverage and has recently expanded the targeting to include informal workers in the tourism sector (The Royal Government of Cambodia, 2023[25]). In Myanmar, health insurance is only available to civil servants (Nikoloski, McGuire and Mossialos, 2021[26]). In addition, a Hospital Equity Fund was piloted to give poor people access to hospital services in one‑third of the country in 2015, although the proxy means test performed poorly: 93% of individuals who met the inclusion criteria in an evaluation study did not receive benefits, whereas 23% of those not meeting the criteria did receive benefits (Htet, Ludwick and Mahal, 2019[27]). The government did intend to introduce a basic Essential Package of Health Services accessible in each township for the entire population between 2017 and 2020, to be expanded stepwise to a comprehensive package of essential health services by 2030 and hence reach universal health coverage (Ministry of Health and Sports of the Republic of the Union of Myanmar, 2016[28]), although by the time of the military coup in February 2021 neither the exact list of services nor the financing mechanism had been defined (Center for Policy Impact in Global Health, 2021[29]).

Removing financial barriers to healthcare use is crucial but not sufficient to reach full healthcare coverage. Beyond financial barriers, the low availability of healthcare services impedes healthcare use. ASEAN countries have limited healthcare capacities compared to the OECD average: on average, they have less than half the number of hospital beds as OECD countries relative to the size of the population, and one‑third of the number of doctors and nurses (Figure 3.4). The available healthcare resources vary greatly between countries in these three domains, with the Philippines for instance having a very low number of hospital beds relative to its population but a very high number of nurses, whereas the opposite is the case in Viet Nam.

Universal health coverage not only depends on coverage and access of health services, but also on the range of health services that are included. Benefit packages offered by social health insurance can vary across a range of aspects, including whether they cover primary, secondary or tertiary care,9 outpatient or inpatient care, healthcare or long-term care. In Lao PDR, Myanmar and the Philippines, only basic healthcare services are covered whereas a wide range of services including tertiary care is covered in Brunei Darussalam, Malaysia, and Viet Nam. Yet, medical check-ups are not covered by health insurance in Viet Nam, and the benefit ceiling on social health insurance in the Philippines is an obstacle for people with conditions requiring costly treatment to receive the treatment they need (Lim et al., 2023[14]). The types of health services covered vary widely depending on the level of insurance chosen in Indonesia, and on the social insurance scheme each person is covered by in Singapore and Thailand (Myint et al., 2019[32]). Furthermore, Indonesia aims to vastly expand mental health services in public health centres around the country (Ministry of Health of the Republic of Indonesia, 2015[33]). The aim is to tackle mental health and the connected stigma, as depressive disorders are a large source of years lived with disability in the country (Agustina et al., 2019[6]).

Problems of availability and accessibility of healthcare services are often more pronounced in rural areas. In the Philippines, despite the entire population in principle being covered by health insurance, only half of the population in some rural areas, mostly underserved areas with a poor population, had medical treatment covered by PhilHealth between 2018 and 2021. In comparison, in some urban areas virtually the entire population had received covered treatment over the same period (Flaminiano et al., 2022[34]). In addition, even if some medicines are free and others can be purchased at a 20% discount for older people, they are not always available (Cananua-Labid et al., 2024[35]). Hence, uncertainty over whether medicine for treatment will be available may discourage some people from seeking medical assistance, in particular if it requires long travel. In Indonesia, rural communities account for 45% of the population but less than 10% of doctors (Agustina et al., 2019[6]). Primary healthcare is mainly delivered by community health centres (puskesmas), which are not yet present in each sub-district.

Households with older people are much more likely to spend at least 10% of their budgets on health than other households, in particular when it concerns households consisting only of people aged 60+ (Figure 3.5). This pattern emerges in all ASEAN countries for which data are available, irrespective of whether the share of all households with high healthcare spending is low, as in Indonesia, or high, as in Cambodia. This pattern is not the result of older people being more likely to live in rural areas as the share of households spending over 10% of the household budget on health is the same for urban and rural environments, except in Cambodia and Viet Nam where it is higher among rural households.

Spending on preventive care as a share of GDP is on average at a similar level in ASEAN and OECD countries, which is remarkable given substantial differences in economic development. On average, ASEAN and OECD countries spend 0.5% of GDP on preventive care (Figure 3.6). Spending on preventive care does vary significantly between ASEAN countries, ranging from around 0.3% in Lao PDR and Thailand to around 0.8% in Indonesia and Malaysia. Indonesia particularly invests in monitoring, likely connected to the posyandu programme of following up the health of mothers and children as well as of people aged 45+. For the latter, the programme particularly monitors the nutritional status and related diseases such as diabetes and hypertension, although its utilisation is limited (Trisfayeti and Idris, 2022[37]). In Cambodia and Malaysia, the largest part of preventive care spending is on immunisation.

Yet, ASEAN countries’ spending on preventing bad health as well as on rehabilitation efforts to reduce the prevalence of disability following injury or illness remain insufficient. While ASEAN countries on average spend as much as OECD countries on preventive care, the level of spending on preventive care in the OECD falls short to effectively improve health in later life and reduce health inequalities (OECD, 2017[38]). Furthermore, spending on rehabilitation, which reduces the prevalence of disability after illness or injury, is very limited in the region: the five ASEAN countries for which data are available on average spend 0.03% of GDP on rehabilitation, roughly one‑tenth of the OECD‑32 average.

As ASEAN countries have become more effective at tackling infectious diseases, non-communicable diseases connected to unhealthy lifestyles became a more prominent driver of mortality, long-term illnesses and healthcare spending (Agustina et al., 2019[6]). While in 2000, fewer than half of deaths were caused by non-communicable diseases in Southeast Asia, by 2019 this had increased to 69% (WHO Regional Office for South-East Asia, 2022[39]). Tobacco use, including smoking, is the only key metric on non-communicable diseases for which there has been a significant improvement in ASEAN countries, as tobacco use has declined since 2000. The share of the population aged 15+ using tobacco has declined from 35% on average across ASEAN countries in 2000 to 24% in 2022, along the line of the average decline in the OECD, from 35% to 22% over the same period. Particularly sharp drops of over 20 p.p. have occurred in Cambodia, Lao PDR and Myanmar (Figure 3.7, Panel A). Indonesia is the only ASEAN country where tobacco use has increased over this period; in Brunei Darussalam and Singapore, the level has remained constant around 16‑17% of the population aged 15+ since 2000. The share of the population using tobacco is still at least double the global target of 19% in Indonesia and Myanmar (WHO Regional Office for South-East Asia, 2022[39]).

In contrast, alcohol consumption, obesity and hypertension prevalence have risen across the region. Alcohol consumption has increased on average in ASEAN countries, from 3.1 litres of pure alcohol per person aged 15+ in 2000 to 4.9 litres in 2019, although it remains far below the OECD average of 9.3 litres. This increase is largely the consequence of increases of more than 6 litres in Cambodia and Viet Nam and over 3 litres in Lao PDR over this period. Alcohol consumption declined somewhat in Singapore and Thailand over this period.10 Obesity is on the rise in all ASEAN countries, affecting 12% of adults in ASEAN countries on average in 2022 compared to only 5% two decades earlier (Panel C). On average across OECD countries, the obesity rate has increased from 16% to 23% over the same period. The rise has been particularly steep in Brunei Darussalam, increasing by 24 percentage points to reach 32%, and Malaysia, where a 17‑p.p. increase has resulted in an obesity rate of 22%. Also, Indonesia, Singapore and Thailand have recorded increases of around 10 p.p. in their obesity rates. Finally, hypertension prevalence has increased somewhat from 31% in 2000 to 34% in 2019 on average, whereas it has declined slightly in the OECD on average from 38% to 34% (Panel D). It has risen in all ASEAN countries except Singapore where it has dropped by 7 percentage points, with the sharpest increases of around 10 p.p. in Brunei Darussalam and Indonesia.

Diet plays an important role in the prevalence of obesity and hypertension, as well as other diseases like diabetes. In Indonesia, for instance, average consumption of refined sugar, fat and salt exceeds the recommended daily amount whereas the intake of animal protein is well below the recommended amount and the consumption of fruits and vegetables is even less than one‑quarter of the recommended amount. Several countries in the region, including Indonesia, the Philippines and Thailand, rely on special taxes on tobacco, alcohol or sugar-sweetened beverages to reduce consumption and finance healthcare (Agustina et al., 2019[6]; Department of Health of the Philippines, 2018[7]; Sumriddetchkajorn et al., 2019[40]).

Beyond generating revenues, health taxes can result in healthier lifestyles as higher prices for unhealthy products can motivate people to limit their consumption (OECD, 2024[41]). They may furthermore prompt producers to replace taxed substances in their recipes, such as sugar, for less unhealthy alternatives.11 Health taxes are less effective in border regions with neighbouring countries where harmful products are cheaper, and if close substitutes of a product that are also harmful are not covered. On average across OECD countries, revenues from excise taxes on alcohol have declined since 2000 despite increasing excise rates due to reduced consumption.12

Injuries, in particular from traffic accidents, are another important source of disability and death in the region. Injuries are responsible for 9% of deaths and 10% of disability-adjusted life years in Southeast Asia, with road accidents being the largest contributor – almost one‑quarter of all injury-related deaths and one‑third of all injury-related disability-adjusted life years are caused by traffic (WHO Regional Office for South-East Asia, 2022[39]). Traffic-related mortality is particularly elevated in Thailand, at double the regional average of 16 annual deaths per 100 000 people (WHO Regional Office for South-East Asia, 2022[39]). In the Philippines, accidents are the fifth leading cause of death of which most are traffic-related (Department of Health of the Philippines, 2018[7]).

Primary healthcare and preventive care play an increasingly important role in the healthcare systems of several ASEAN countries. With the passing of the new health law in 2023, Indonesia shifted the focus of its healthcare system from curative towards preventive care, through stepping up efforts to improve health knowledge, immunise and screen the population in order to reduce prevalence and increase early detection of health problems (Wijayanti, 2023[12]). Malaysia’s Health White Paper highlights the importance of primary healthcare in monitoring health and preventive care, including through public information campaigns and setting financial incentives to boost healthier lifestyles (Ministry of Health of Malaysia, 2023[42]). While public information campaigns are important tools to boost health knowledge and improve preventive care, they have to be designed carefully to be impactful. The Philippine Department of Health assesses that previous health-knowledge campaigns have not been very efficient in terms of reducing spending on curative care as they have mostly been targeting people who were already sick, rather than on preventing others from becoming sick (Department of Health of the Philippines, 2018[7]).

Income inequality is deeply entrenched in ASEAN countries and pension systems can only play a limited role to correct the inequality that builds up before retirement. Inequality data for ASEAN countries are limited. While data on labour income inequalities is not available, the World Inequality Database (WID) provides a pre‑tax income inequality measure. This measure combines labour and capital income taxes. Based on the Gini coefficient, which is equal to 1 when one person has all the income and 0 when everyone has the same income, income inequality in ASEAN countries is higher on average than in the OECD, with average Gini coefficients of 0.57 and 0.50, respectively (Figure 3.8). Over the last 20 years, pre‑tax income inequality has decreased in ASEAN countries on average, while there has been a slight increase in the OECD. The average Gini index fell by 1.4 percentage points in ASEAN countries, while it increased by 1.2 percentage points in the OECD. A more relevant measure of income inequality would be after-tax based on disposable household income, thereby accounting for redistribution through tax systems, but this measure is not available in a harmonised way for ASEAN countries. For the OECD as a whole, the post‑tax disposable income measure gives a Gini index for the total population around one‑third lower on average than that for the pre‑tax measure (OECD, 2024[43]). The difference between after-tax and pre‑tax inequality is likely to be much smaller for ASEAN countries as redistribution through the tax and social-protection systems is more limited.

Pension systems in ASEAN countries follow different formats. Some of them have only been in place for a short period of time for private‑sector workers with separate, older schemes being applicable for public‑sector workers. Table 3.1 shows the architecture of pension systems in ASEAN countries based on the rules that determine eligibility and benefit levels. The first tier comprises programmes offering the first layer of social protection in old age, and for which past earnings are irrelevant in the calculation of retirement income. Such schemes often target some minimum standard of living in retirement. Mandatory earnings-related components (second tier) contribute to smoothing consumption, and therefore standards of living, between working life and retirement.

Among fist-tier benefits, basic pension benefits can take two forms: available based on only a residence criterium (residence‑based) or to those who contributed during their career (contribution-based). Only Brunei Darussalam and Thailand have a residence‑based basic pension; in Thailand, there is a proposal to make the benefit means-tested. Six ASEAN countries – Indonesia, Malaysia, Myanmar, the Philippines, Singapore and Viet Nam – have means-tested targeted benefits. By contrast, neither Cambodia nor Lao PDR have either a basic or a means-tested benefit: both countries have no first-tier benefit of any kind for retirees. The Philippines also has a contribution‑based basic pension. Minimum contributory pensions, which refer to either the minimum of a specific contributory scheme or to all schemes combined, exist in three ASEAN countries, Indonesia, the Philippines and Viet Nam. Minimum contributory pensions define a minimum for total lifetime entitlements, which may increase in level once the length of the contribution period exceeds certain thresholds.13

In ASEAN countries, there are three kinds of mandatory earnings-related (second-tier) pension schemes covering private‑sector workers: pay-as-you-go defined benefit (DB), points or funded defined contributions (FDC). For future retirees in the private sector, public pay-as-you-go schemes are DB in five ASEAN countries – Cambodia, Indonesia, the Philippines, Thailand and Viet Nam -, which means that individual benefits are based on the number of years of contributions, accrual rates and pensionable earnings. There is a points scheme in Lao PDR where, at retirement, the benefit is equal to the total acquired pension points multiplied by the estimated average monthly covered earnings of all insured persons in the calendar year before retirement and by 2%. FDC plans are mandatory in five ASEAN countries: Brunei Darussalam, Indonesia, Malaysia, the Philippines and Singapore. In these schemes, contributions flow into an individual account. The accumulation of contributions and investment returns can often be taken as either a lump sum or as a programmed withdrawal. Within the ASEAN countries, all of the FDC schemes are classified as being public because the investment strategy is controlled by government bodies in terms of both the level of risk and the amount of permitted foreign investment, for example. Indonesia and the Philippines have therefore both DB and FDC schemes, though only for high earners for FDC in the Philippines, whilst Myanmar does not currently have any mandatory pension scheme in place for private‑sector workers.

Although public‑sector workers have the same first-tier pensions as those in the private sector, they often have a different earnings-related pension. Only Brunei Darussalam, Singapore and Viet Nam have the same earnings-related pension for both private‑ and public‑sector workers, with Malaysia intending to enrol new public-sector workers into the private‑sector scheme (Employees Provident Fund, EPF) from 2024 while maintaining the separate scheme for current public‑sector workers. Indonesia has the same DB scheme for all employees but those in the public sector have a higher FDC contribution rate, while Cambodia has a higher accrual rate for public‑sector workers than for those in the private sector. In Lao PDR public‑sector workers are covered by a DB scheme with different accrual rates depending on the year they began working.

Four ASEAN countries – Brunei Darussalam, Malaysia, Singapore and Thailand – have assets held in pension funds – as well as Indonesia and the Philippines to a much lesser extent. As they have had fully funded pension systems in place since the 1950s, Malaysia and Singapore have the largest funds in the region (Table 3.2); the Malaysian EPF has assets equivalent to 63% of GDP in 2023 and the Singaporean Central Provident Fund 38%.14 The FDC scheme in Brunei Darussalam also has significant assets, worth 23% of GDP while Thailand is at 13% and Indonesia and the Philippines much lower at under 4% of GDP. Across the OECD, assets in pension plans are equivalent to 49% of GDP on average, although some countries have well-developed funded pensions; for example, assets in Australia, Canada, the Netherlands and the United States are over 130% of GDP (OECD, 2023[44]).

The proportion of the labour force covered by mandatory pensions ranges from 4% in Myanmar to 65% in Thailand (Table 3.3). Being covered means actively making contributions within the last year as either a private‑ or public‑sector worker. The coverage level in Myanmar is much lower than in any other country as there is no mandatory pension scheme for private‑sector workers so only government employees are included. Indonesia and Lao PDR also have low coverage levels at 16% and 10%, respectively, while Brunei Darussalam, Malaysia and Singapore have coverage levels around 60% of the labour force, much higher than in the Philippines (45%) or Viet Nam (29%).

Most retirees are not receiving any pension in the majority of ASEAN countries. In both Cambodia and Lao PDR under 7% of those of retirement age or older receive any pension. In Indonesia, Malaysia, Myanmar and the Philippines, 20% or below of the population above the retirement age get a pension. The figures for Cambodia and Lao PDR (as well as Myanmar) only include public-sector pensions as private‑sector schemes have only recently been introduced. Conversely, everyone in Brunei Darussalam receives a pension as there is a universal (residence‑based) basic pension. In Thailand, 89% of those aged 55 and above receive a pension as it is also residence‑based. Only Viet Nam has over 40% receiving an earnings-related pension.

Residence‑based basic pensions in Brunei Darussalam and Thailand are equal to 11% and 4% of average earnings, respectively (Table 3.4). For the OECD countries shown in the Table, only New Zealand has a residence‑based basic pension, but it is much higher at 40% of average earnings, though there is no mandatory pension in New Zealand. New Zealand is a very special case as, among the nine OECD countries with such a scheme, none of the other eight has a benefit above 30% of average earnings, with the OECD average at 21% of average earnings.

Targeted safety‑net benefits are at a very low level in ASEAN countries, even though, given the limited universal schemes, they should play the key role in dealing with income vulnerabilities. Targeted benefits are generally only around 5‑7% of average earnings; only Malaysia has a higher rate at 16%. These benefits are therefore not of a sufficient level to provide adequate support to retirees. By comparison, the targeted benefit in Australia is worth 28% of average earnings with Japan also above the Malaysian level and the United States equal to it. Only the Philippines has a contribution‑based basic pension at 7% of average earnings, equal to the targeted safety-net. Minimum pensions only exist in Indonesia, the Philippines and Viet Nam at 14%, 16% and 24% of average earnings, respectively. Both Cambodia and Lao PDR stand out as having no form of safety-net protection for older people.

The coverage of first-tier benefits varies enormously across ASEAN countries. The percentage of over‑65s receiving such benefits is shown in the final four columns of Table 3.4. Unsurprisingly, residence‑based basic pensions in Brunei Darussalam and Thailand have the highest coverage. In the Philippines, the contribution-based basic pension is claimed by 35% of the over 65s, which is low in comparison for example to Japan and Korea, at 92% and 57%, respectively. The range in coverage by targeted schemes is wide, with the Philippines having well over 50% of those aged 65 or older in receipt, while recipient levels are under 10% in Indonesia, Malaysia and Myanmar.

In several ASEAN countries, targeting is based on proxy means testing. In a proxy means test, a household’s level of need is determined based on observable living conditions, such as the characteristics of the house the family lives in. Indonesia for instance grants certain targeted benefits to households in a database of poor households constructed on 2005 census data and updated through a targeting census requiring home visits to around 25 million households (thus covering about 92 million individuals) every three‑to-four years (Banerjee et al., 2020[45]). Characteristics of the house itself, as well as the demographics and assets owned by the occupying household, are taken into account in the evaluation. As a result, benefit recipients’ entitlements are connected to the place where they live, and moving to a different area would mean losing the current entitlements and having to re‑apply for assistance. This is also the case in Cambodia, for instance, where people identified as eligible for certain benefits through IDPoor (Section 3.1) may not be able to access their benefits when moving to another municipality (OECD, 2017[46]).

Income poverty rates are high in a number of ASEAN countries, particularly for women. Income inequality amongst adults in ASEAN countries have been relatively high in the past. Moreover, poverty rates are higher in rural than in urban areas and the older population is more heavily concentrated in rural communities (UNDP, 2022[47]). In countries with much younger populations, such as Cambodia, Lao PDR and the Philippines, older people are less likely to be in poverty than the general population (ASEAN, 2024[48]). Conversely, in Indonesia, Malaysia and Thailand, countries with much older populations, the poverty rate of older people is higher than that of the general population. Filial support is still prevalent in many ASEAN countries; for example, in Cambodia and Lao PDR, family transfers represent 62% and 72% of the total income of households composed only of older people (Asian Development Bank, 2024[49]). In Thailand, the level, while still quite high, is lower at 37% suggesting that as populations age and there are fewer younger family members available to provide support, the filial level of transfers decreases and consequently poverty rates increase.

As in OECD countries, older women typically have a higher poverty rate than older men (ASEAN, 2024[48]). Family and domestic responsibilities have prevented many women from having paid and full-time jobs. Moreover, those women who work are still expected to provide care in the household, and therefore many have informal employment, which is generally low paid. This leaves women with limited social protection and being financially dependent on other family members, thereby becoming more vulnerable to poverty in their later years.

Creating a social pension that is effective in helping to alleviate poverty is therefore a priority. While this will be costly in the short-term, over time the cost should fall significantly if the earnings-related part offers incentives to participate and the different pension schemes are well co‑ordinated. Moreover, as ASEAN countries are currently relatively young, the related short-term financial costs are limited.

In many ASEAN countries, pension contribution rates are low, well below those in the majority of OECD countries. Across ASEAN countries the contribution rate is currently 12.9% on average, split as 5.1% from employees and 7.7% from employers with 0.1% from government (Table 3.5). By comparison the OECD average contribution rate is 18.2%, with average earners in both France and Italy contributing more than 27%. Malaysia, Singapore and Viet Nam have total contribution rates above 20%. By contrast, total contributions in Lao PDR are only 5% of earnings, with Thailand at 7.0%, Indonesia at 8.7% – 3.0% for DB, 5.7% for FDC – and the other countries above 10.0%. In Cambodia, the total contribution rate is 4.0% currently, increasing to 10.75% by October 2032, equally split between employee and employer, resulting in an average of 9.5% for a full-career worker starting at age 22 in 2022.

Retirement ages in ASEAN countries are low compared to those in OECD countries with limited legislated increases. The OECD defines the normal retirement age in a given country as the age of eligibility to pensions from all schemes (covering either public- or private‑sector workers) without penalty.15 On average across ASEAN countries, the normal retirement age for male private‑sector workers who retired in 2022 was 59.2 years compared to an OECD average of 64.4 years ranging from a low of 55 years in Malaysia and Thailand to a high of 63 years in Singapore with half the countries at age 60 (Figure 3.9). Women have the same retirement age as men except in Lao PDR and Viet Nam, where it is 5 years and 4 years 10 months lower. In Viet Nam, with the increase in the retirement age since 2021, it will reach 62 for men by 2028 and 60 for women in 2035, reducing the future gender gap to 2 years. Gender gaps exist in nine OECD countries including Colombia and Poland, where women can retire five years earlier than men.

The current gap between the average normal retirement age in ASEAN and OECD countries largely reflects current differences in old-age life expectancy. Remaining life expectancy at age 60 is 20.0 years for men in ASEAN countries on average currently, compared with 24.2 years in the OECD on average and 20.1 years at age 65. By 2065, remaining male life expectancy is projected to increase to 23.6 years in ASEAN countries at age 60 and to 24.0 years for OECD countries at age 65.16

The legislated increases in retirement ages are in ASEAN countries on average half those in the OECD while life‑expectancy gains in old age are projected to be similar. With legislated increases in normal retirement ages, the normal retirement age for men will increase to 66.3 years in the OECD on average for those entering the labour market today, but it will only go to 60.2 years for ASEAN countries, with only Indonesia, Singapore and Viet Nam having legislated an increase – since 2016 the retirement age in Indonesia has been increasing by one year every three years to reach 65 by 2043. Given projected health improvements, stabilising pension replacement rates in ASEAN countries in a financially sustainable way would require higher contribution rates if retirement ages do not increase much more.

The old-age pension replacement rate measures how effectively a pension system provides a retirement income to replace earnings while working. Under the baseline assumptions, workers earn the same percentage of average‑worker earnings throughout their career. Therefore, final earnings for full-career workers are equal to lifetime average earnings revalued in line with economy-wide earnings growth. Replacement rates expressed as a percentage of final earnings are thus identical to those expressed as a percentage of lifetime earnings. For comparability across countries all benefits that can be taken as a lump sum have been annuitised over the remaining lifetime.

Across ASEAN countries future pension entitlements for average earners are below those within the OECD. Male average earners in ASEAN countries will on average have a net replacement rate – defined as the individual net pension entitlement divided by net pre‑retirement earnings, taking account of personal income taxes and social security contributions paid by workers and pensioners – of 57.3% after a full contributory career from age 22 (Figure 3.10). This compares to 61.4% for the OECD average. Given the much lower contribution rates shown in the above Table, this replacement-rate difference between ASEAN and OECD countries on average is relatively limited, potentially reflecting better demographics in ASEAN countries in the short term but also more serious financial sustainability issues that are discussed in another section below.

Within ASEAN countries, net replacement rates for full-career workers are the lowest in Brunei Darussalam for average earners at 35.0% compared to a high of 86.3% in Lao PDR and 76.3% in the Philippines (Figure 3.10). However, as shown above, the coverage level is currently very low in Lao PDR and of only about 20% in the Philippines. The remaining countries have replacement rates between 43% and 56% with the exception of Singapore and Viet Nam at 65%.

Future replacement rates for low earners – those earning 50% of the average wage – are low even after a full career in Cambodia – close to 50% or less implying pensions close to one‑quarter of net average wages or below. This is comparable to Canada (54%), Japan (50%), Korea (51%) but is well below the OECD average of 73% while the ASEAN average is 59%. The gap between the ASEAN and OECD average is wider for low earners than for average earners as there are low first-tier benefits and limited redistribution within the pension system in ASEAN countries as highlighted above. However, in Brunei Darussalam, and to a lesser extent in the Philippines and Thailand, the basic pensions (whether residence‑based or contribution‑based) are worth more in relative terms for low earners, and as a result their replacement rates are higher than for average earners.

Higher earners with full careers – those earning 200% of the average wage – have similar replacement rates on average in ASEAN countries compared to the OECD average. There are two main reasons for the convergence in results for high earners. First, safety-net or flat-rate benefits are generally more generous in OECD countries, and they have a reduced impact on replacement rates for higher earners. Second, many OECD countries apply ceilings to contributions to their pension systems, which lowers the future pension entitlements from earnings-related pensions for the higher earners, while ceilings are less common in ASEAN countries. Redistribution within pensions that applies in several OECD countries plays a smaller role, whether through a progressive benefit formula, as in the United States for example, replacing lower incomes at a higher rate, or though part of pension entitlements being based on economy-wide contributions, as in Korea. Unusually, in Lao PDR the net replacement rate actually increases with earnings as pensions are not taxed while taxes on earnings are progressive, meaning that the same gross replacement rate across earnings levels leads to higher net values as earnings increase.

Even if based on the same career, age and earnings levels, women will have lower future pension entitlements than men in Lao PDR and in ASEAN countries with FDC schemes. On average, the net replacement rate for women will be 2.9 percentage points lower than for men at the average wage in ASEAN countries, compared to only 0.8 percentage points lower in the OECD (Figure 3.11). Lao PDR has the largest difference, at 10.6 percentage points, entirely due to women retiring 5 years earlier than men, thereby having accumulated lower pension entitlements. In Brunei Darussalam and Singapore, sex-specific mortality tables are used to calculate pension annuities from FDC schemes, as well as in Australia and Latin American OECD countries. This negatively affects women’s replacement rates as their higher life expectancy lowers annuity payments. The same happens in Malaysia and in Indonesia for its FDC scheme, but through a different mechanism. There, no annuities are provided and it is possible to take the entire pension pot as a lump sum at retirement age, generating larger risks that women consume their lump sums before they die as they are expected to live longer. This is therefore reflected in lower replacement rates as calculated by the OECD. However, within EU countries, common mortality tables must be used for both men and women, thereby providing an element of redistribution towards women when calculating retirement incomes, which helps reduce the gender pension gap. Viet Nam actually shows a higher replacement rate for women than for men despite women retiring two years earlier as the base accrual rate of 45% is reached after only 15 years of contribution for women compared to 20 years for men. These replacement rate numbers are based on the assumption of full careers with the same earnings levels for men and women, while in reality as women tend to work for much shorter periods than men and at lower wages, their pensions will effectively be much lower and poverty risks be much higher.

One way to examine whether contributions are enough to finance pensions for given career cases is to compare the implicit rates of returns they generate for individuals with the internal rate of return that the system can afford. Using the latest UN projections for mortality data, the implicit rate measures the effective return on contributions paid that generates the flows of projected pension benefits based on current legislation and projected mortality rates. This flow of benefits accounts for the increases in benefits throughout retirement, which for Cambodia, the Philippines and Viet Nam is based on wage indexation whereas it is price indexation for the other countries.

The internal rate of return in a pay-as-you-go scheme is assumed to be equal to the growth rate of the contribution base, i.e. the sum of employment growth and wage growth; the latter is in turn assumed to equal labour productivity growth, which is assumed to be 1.25% per year in real terms. Employment is supposed to grow as the working-age population. Projections of the latter account for legislated increases in the normal retirement age. ASEAN countries that have the same replacement rates from a DB scheme within the range of earnings modelled herein have the same implicit rate of return as contribution ceilings are above twice average earnings. The implicit rate of return in funded schemes is determined by investment returns and annuity calculations. In pure FDC schemes, there is no issue of financial sustainability, and the internal rate of return is equal to the implicit rate. In both DB and DC schemes, a higher wage growth broadly raises one‑to‑one both internal and implicit rates, with therefore some limited impact on the difference between both rates, which is the focus here. The only small caveat refers to Cambodia, Indonesia and Thailand, as DB pensions there during retirement are price indexed. This means that higher wages driven by higher productivity growth are not fully reflected in pension levels after retirement. For example, if annual real wages were to grow faster by 1 percentage point, thereby raising internal returns by 1 percentage point, implicit returns would increase by only about 0.8 percentage points, improving financial sustainability slightly.

The internal annual real rate of return is around 2% for most of the ASEAN countries but is much lower in Thailand, as well as in Viet Nam to a lesser extent. This is because these two countries are projected to face declining working-age populations over the next decades, which affects the financing of their pay-as-you-go pensions (Figure 1.1) as this measure is based on the projected changes in the size of the working‑age population, which accounts for legislated increases in retirement age. The result for Indonesia, for example, uses a long-term retirement age of 65, but is only 58 currently. The level in Thailand is lowest at 0.2% as the long-term retirement age is not increasing from age 55 and the demographic situation is poor with low fertility and rapid ageing. If the retirement age were to be increased to 60 in Thailand for workers starting today the internal rate of return would increase to 0.8%.

The implicit annual real rates of return are close to 5% or more for the DB schemes in Indonesia and Thailand, and even much higher in Lao PDR. Due to extremely low contribution rates relative to the pension promise – 5% contribution rate and 2% accrual rate – the implicit rate of return in Lao PDR is above 8% for average and high earners and even 14% for low earners (Figure 3.12). In Indonesia (for the DB scheme) and Thailand also, the contribution and accrual rates are not balanced (3% contribution rate for 1% accrual rate and 7% contribution for around 1.4% accrual, respectively) thereby giving implicit rates of return of 5‑6%. Likewise in Cambodia, the Philippines and Viet Nam, the accrual rates of 1.25%‑1.75%, 2% and 2%‑3%, respectively, are unsustainable given the level of contribution rates; as the latter are higher than in Lao PDR, Thailand and Indonesia, at 9.5%, 15% and 22%, respectively, the implicit rates of return are lower. In Cambodia and Viet Nam, in addition, past wages are uprated with price inflation rather than wage growth, which diminishes effective accrual rates (compared to their nominal value above), replacement rates and implicit rates of return.

As a result, the implicit rates of return are much higher than the internal rates in ASEAN countries with pay-as-you-go pensions, casting doubts about their financial sustainability. This is the case in particular of Lao PDR and Thailand, but as well of Indonesia, and to a lesser extent Cambodia, the Philippines and Viet Nam. Increasing the retirement age would help to improve pension finances, as more contributions would be received and pensions would be paid for a shorter period of time, but this will fall short of ensuring sound finances in some cases. For example, in Thailand, if the retirement age were increased from 55 to 60 years, the corresponding implicit real rate of return would only fall to 5.3% from 6.0% for an average earner, still well above the 0.8% for the internal rate of return.

In almost all of the ASEAN countries, self-employed workers are not mandatorily covered by the pension system but rather rely on voluntary contributions. Brunei Darussalam, from 2023, and the Philippines are the only countries to have fully mandated pension coverage for this group. Voluntary coverage is not even possible in Indonesia for the DB component as the self-employed are not allowed to join.

Contribution rates for the self‑employed are often either flat rate or at a lower percentage than those for employees.17 In Brunei Darussalam, for example, the self‑employed contribute between BND 17.5 and BND 40.0 per month (0.7% and 1.7% of gross average earnings, respectively) with a matching contribution of BND 17.5 from the government, whereas, for employees, employers contribute between 8.5% and 10.5% of earnings – there is no contribution from employees themselves. Thailand also has flat-rate contributions to social insurance for the self-employed, equivalent to a maximum of around 1.2% of average earnings but there is also an additional separate pension system for the self‑employed (Social Security Fund) with the government matching contributions at between 50% and 100% depending on age and subject to a ceiling. In Indonesia, the DB scheme is not an option for the self-employed; if joining the FDC scheme they must at least contribute the 2% rate that dependent employees pay to the Provident Fund, but there is no requirement to pay the 3.7% employer contribution. In Lao PDR, the Philippines and Viet Nam, the self‑employed pay the equivalent of both the employee and employer contribution, but there is a lower floor to starting contributions in the latter. Finally, in Malaysia and Singapore there are the same ceilings to contributions, but how much is contributed is totally at the discretion of the self‑employed worker.

The schemes for the self‑employed are entirely separate in both Thailand and Viet Nam whereas in other countries the voluntary contributions of the self‑employed go into the same schemes as for private‑sector workers. Therefore, the coverage levels shown in Table 3.3 include self‑employed workers for most countries but not for Thailand and Viet Nam, which when included increase the coverage level by 5.6 percentage points and 2.7 percentage points, respectively.

Older people’s capacity to remain active in society depends among other factors on their living arrangements and their capacity to get around. Living arrangements affect the availability of support to overcome difficulties with personal care or domestic help, allowing older people to live their lives. Older people’s integration in the community can be improved by supporting them in the execution of tasks they have difficulties with and by providing them with opportunities to connect and maintain their social networks. Social participation does require that people are able to move around in their own homes, their neighbourhoods and the wider environment. Finally, older people in need of an income or long-term care may have to relocate in search of job opportunities or care providers such as family members. Therefore, this section explores two areas in relation to where older people live and how they move around in the light of active ageing: housing arrangements and community life, and mobility of older people.

Home ownership provides a stable living environment that facilitates the development of durable social connections in the community. With the exception of the Philippines, where only 57% of households live in an owner-occupied home, the home‑ownership rate ranges between 77% in Thailand and 89% in Singapore, compared with 71% in the OECD on average (Figure 3.13).

Living in a multigenerational household provides opportunities for social interaction. The share of older people living alone or only with a partner is used as an indicator of active ageing in the Active Ageing Index, developed by the European Commission and UNECE as a tool to assess older people’s ability to control their own lives and (capacities for) participation in both society and the economy (UNECE / European Commission, 2019[50]). It is based on the assumption that a setting in which older people can live independently must be supportive to older people. At the same time, however, multigenerational households provide opportunities for social interaction and for older people to contribute to the household’s welfare through the provision of childcare, facilitating in practice the labour market participation of their daughters or daughters-in-law.

Multigenerational households are very common in ASEAN countries. On average in the seven ASEAN countries for which data are available, 46% of people aged 65+ live in a household comprising at least three generations (Figure 3.14). This ranges from around 30% in Thailand to over 60% in Lao PDR. In Malaysia the share is likely to be somewhat lower than in Thailand as only about one‑third of people aged 60+ live in a multigenerational household, which also includes two‑generation households (Asian Development Bank, 2023[57]).18 Moreover, in Malaysia, multigenerational households are more common in urban than in rural areas, which is likely the result of migration of younger generations away from rural areas and higher housing costs in urban areas making co-housing a more attractive option for urban families (Mohd, Senadjki and Mansor, 2017[58]). In addition, across ASEAN countries 5‑10% of older people live in “skip-generation” households, meaning that grandparents cohabitate with their grandchildren, but not with the generation in between. Skip-generation households are particularly common in rural areas where parents migrate in search of better jobs. The main reasons for Thai people to live in this type of household include family care norms, unavailable or unaffordable formal childcare options, problematic family relationships and financial agreements to provide care in exchange for remittances (Ingersoll-Dayton et al., 2018[59]).

Grandparenting can have substantial positive impacts on active ageing. In the Active Ageing Index, grandparenting is considered a form of participation in society, and thus a component of active ageing (UNECE / European Commission, 2019[50]). In addition to looking after children, grandparents support grandchildren in essential daily activities such as feeding, bathing, and providing educational support, particularly in households with working parents or skip-generation households (Mehta and Thang, 2012[61]). Their roles extend beyond daily caregiving to encompass education and cultural transmission by passing down traditions, values, and languages (Hoang and Kirby, 2019[62]; Thang et al., 2011[63]). Providing childcare can also enhance grandparents’ social networks as public spaces such as parks and libraries provide opportunities for interactions with other grandparents and parents (Mehta and Thang, 2012[61]). Older people’s involvement in grandparenting can reduce loneliness, increase social interactions, and improve mental well-being (Abdullah et al., 2024[64]; Chung and Park, 2017[65]). In Myanmar and Viet Nam, grandparents generally perceive significant benefits from their caregiving roles including gaining a sense of purpose, enjoying the company of their grandchildren, and deriving satisfaction from helping their adult children by caring for their grandchildren (Knodel and Nguyen, 2015[66]).

Grandparents play an important role in caring for, raising and educating children in ASEAN countries. As public early-childhood education and care services are limited in ASEAN countries, in particular for children below age 3, grandparents are a key provider of childcare.19 In Myanmar, Thailand and Viet Nam, many grandparents co-residing with their grandchildren take on substantial caregiving responsibilities, in particular grandmothers (Knodel and Teerawichitchainan, 2018[67]). Roughly one‑third of people aged 60+ with children provide childcare for grandchildren younger than 10 in Myanmar and Viet Nam; 28% do so in Thailand, likely reflecting the lower fertility rate. In the Philippines, one‑quarter of people aged 60+ take care of grandchildren partially or fully, 82% of which live in with grandchildren (Cruz, Cruz and Saito, 2019[68]). Older people often continue to provide care even if they need care themselves. In Myanmar, for instance, grandparents and grandchildren often provide mutual support (Knodel and Nguyen, 2015[66]; Teerawichitchainan and Knodel, 2017[69]).

At the same time, care provision may have negative consequences in terms of health, financial independence and time available to pursue other activities. Regular childcare provision reduces participation of grandmothers in social activities (Arpino and Bordone, 2017[70]), in particular when cohabitating with grandchildren (Bulanda and Jendrek, 2014[71]). As societal norms and family structures evolve, there is a growing appreciation among older adults in various regions of Asia for personal independence (Rahut and Destefanis, 2024[72]). Hence, in absence of formal childcare policies in most ASEAN countries in particular for young children, childcare expectations of parents and grandparents may become increasingly conflictual in the future. If grandmothers leave paid labour to look after their grandchildren, grandparenting may reduce their financial independence. Furthermore, while Thai grandparents providing childcare to their grandchildren are in better health than other grandparents, this is the consequence of grandparents in better health taking up an active role as caregiver. Once this selection effect is accounted for, providing childcare has been estimated to have a negative impact on grandparents’ health (Komonpaisarn and Loichinger, 2019[73]). This could be the consequence of the arduousness of the care provision itself, as well as of grandparents who provide regular childcare being more likely to neglect medical appointments, exercise routines and social activities for themselves (Winefield and Air, 2010[74]).

Several ASEAN countries have implemented policies to provide opportunities for older people living in the community to participate in social activities. They consist of community centres providing social activities that older people can participate in. Tackling social isolation of older people is one of their key objectives. Brunei Darussalam has five Senior Citizen Activity Centres (PKWE), established under the Ministry of Culture, Youth, and Sports in 2013. While their primary goals include tackling social isolation of older people and promoting life‑long learning for instance through ICT and handicraft courses, they also play a role in preventive care. In Malaysia, Senior Citizens Activity Centres (PAWE) provide social and religious activities with an explicit aim to strengthen intergenerational bonds: while the main target group consists of people aged 60+, the centres aim to build bridges across generations by bringing younger generations into their activities. This is, for instance, achieved through bringing in younger people to teach digital skills or English.20 The Philippines has a network of 87 Senior Citizens Centres organising activities for older people overseen by the Department of Social Welfare and Development.21 These centres foster partnerships with governmental and non-governmental entities to deliver healthcare services, volunteer training, and community projects, aiming to enhance the well-being and social engagement of older community residents. In Singapore, Active Ageing Centres provide social and sport activities to older people (Singapore Ministry of Health, 2023[75]). Singapore plans to expand its network of centres from 157 in 2024 to 220 by 2025 so that 80% of older people have a centre in their neighbourhood (Age Well SG, 2024[76]). The centres also establish a support network for older adults, which includes other seniors, volunteers, and healthcare professionals. These networks are meant to identify people at risk of social isolation or in need of support and engage them in the centres’ activities. Thailand has promoted clubs for older people to increase social participation among older adults through vocational development, exercise, and arts and crafts (Japan International Cooperation Agency, 2022[77]). Finally, Viet Nam’s Intergenerational Self-Help Clubs (ISHC) organise community-based intergenerational activities and lifelong learning (HelpAge International, 2023[78]). Through the National ISHC Replication Project, the government actively supports the establishment and operation of these clubs.

The community centres for older people often combine providing social activities with some care‑related functions, such as providing or supporting LTC provision to older people or performing preventive‑care activities. The Senior Citizen Activity Centres in Brunei Darussalam perform activities promoting healthy lifestyles, and organise health screenings (WHO, 2024[79]). In Malaysia, Senior Citizens Activity Centres provide health checkups and promote healthy lifestyles through providing information and activities such as sports or vegetable gardening.22 The Senior Citizen Centres in the Philippines can follow up older people after discharge from hospital, organise community networks to provide support to older people living in the community with LTC needs, and organise institutional care for older people who can no longer care for themselves and cannot rely on family care (Loa, 2022[80]). In Singapore, Active Ageing Centres fall under the responsibility of the Ministry of Health and provide various care services including day care and monitoring of older people (Singapore Ministry of Health, 2023[75]). Most clubs for older people in Thailand are located in community health centres or hospitals, and in Viet Nam these organisations among others promote healthy lifestyles.

Some of these programmes also provide activities to help older people earn an income. In Brunei Darussalam, the centres provide entrepreneurship programmes providing information on entrepreneurship to older people as well as offer opportunities for older people to showcase their work (WHO, 2024[79]). In Malaysia, the centres give classes to acquire and develop marketable skills for instance in terms of food production or handicrafts, as well as offer opportunities for volunteering.

As people age, they often become more reliant on other forms of transport than driving a car or motorcycle. Disabilities such as loss of eyesight may make driving more difficult or dangerous. Older people may furthermore not have an income that is high enough to cover the cost of owning and driving a personal vehicle. In Jakarta, for instance, half of all microbus passengers are older people.23 Hence, available, accessible and safe public transport is important to ensure older people maintain a certain level of mobility, which contributes to the quality of their life and supports their continued participation in social life and in the workforce. Public transport is a key component of designing age‑friendly environments and of active ageing as older people in ASEAN countries are more likely to partake in activities if there is an accessible bus station in their neighbourhood (Tiraphat et al., 2021[81]).

In Singapore, older workers rely particularly on public transport for their daily commutes. In 2021, 40% of workers aged 57‑76 use the subway and around one‑quarter walk (Wong, Tan and Cheong, 2022[82]).24 Furthermore, half of older workers use the bus to commute to work, and even two‑thirds of those with a disability affecting their mobility. Indeed, buses are fully accessible for people with disabilities: all buses as well as bus interchanges and 98% of bus shelters in Singapore are barrier-free and wheelchair accessible.25 Often, a single commute by public transport combines multiple modes, including walking. Only 21% use their personal car to commute to work, which is usually not combined with any other mode of transportation. Transport modes differ somewhat across genders: older men are more likely than women to rely on private motorised modes of transport, whereas older women are more reliant on public transport (Hou et al., 2020[83]). Overall, older Singaporeans are satisfied with their way of commuting, although satisfaction depends on the duration of the commute and the dominant mode of transportation – people mostly relying on active forms of transport such as walking are most satisfied, followed by people making use of private transport and then public transport (Wong, Tan and Cheong, 2022[82]).

However, older people in Malaysia strongly rely on their private car for transportation. Over 60% of older Malaysians mostly rely on their car for transport, compared to 15% relying on public transport (Noor et al., 2022[84]). There are some important differences between urban and rural areas, with older people in rural areas relying somewhat more on bus transport and less on private vehicles compared to older people in urban environments. Moreover, cities can differ starkly in terms of the available public-transport infrastructure, affecting older people’s ability to rely on public transport. Older Malaysians are more responsive than other population groups to changes in travel cost and time of public transport, in distance to the public-transport access point and in frequency of public-transport services compared to younger generations (Noor et al., 2022[84]).

Reduced fares are a common initiative to increase older people’s use of public transport services. In Brunei Darussalam, Cambodia, Indonesia, Malaysia, the Philippines, Singapore, Thailand and Viet Nam, older people benefit from discounts on public-transport fares, often travelling at half the regular price. Locally, discounts may be even more substantial: the city of Hanoi, for instance, introduced free bus travel for people aged 60+ in 2024. Indeed, subsidising the price of a ticket is important for older people’s choice of transport mode in Malaysia and Viet Nam for example (Hoang Thuy et al., 2022[85]). In Thailand, although the use of urban rail and buses by older adults correlates with fare reductions (Thaithatkul et al., 2022[86]), out of a list of 10 topics in relation to public transport, affordability was the least important to people aged 60+ – they in particular valued regular, punctual services and short waiting times, as well as safety and accessibility, including ease of embarking and disembarking (Chaisomboon, Jomnonkwao and Ratanavaraha, 2020[87]).

Gender inequalities in certain rights as well as underdeveloped long-term care policies infringe on women’s ability to participate actively in society. They limit women’s independence to engage in the types of activities they would prefer and limit the time and financial resources available to them to do so.

Gender discrimination in Southeast Asia is very prominent in the family sphere (OECD, 2024[88]). The OECD’s Social Institutions and Gender Index (SIGI) is constructed based on indicators measuring unequal rights to divorce, inheritance or guardianship over children, and a minimum legal age of marriage for girls under the age of 18 years. On a 100‑point scale with a higher score indicating more discriminative laws in the family sphere, women fare far worse in ASEAN countries than in the OECD on average in this area, with a score of 54 compared to 14 (Figure 3.15). Gender discrimination in family and inheritance laws is very high in Brunei Darussalam, Indonesia and Malaysia, with scores of 80 or higher. Cambodia and Lao PDR in contrast have substantially lower scores around 20‑25, which remains well-above the OECD average but is comparable to OECD countries such as Korea. The prevalence of gender discrimination in family and inheritance laws may among others hamper women’s ability to participate in the labour market. The gender gap in labour force participation rate correlates relatively strongly across countries with the score on discrimination in the family, with a linear correlation coefficient of 0.55 across 169 countries.

In all but three ASEAN countries, the different treatment of men and women is formalised through personal status laws, i.e. statutory and customary laws that apply only to particular religious, ethnic or cultural groups within a national jurisdiction (OECD, 2024[88]). All ASEAN member states except Cambodia, Lao PDR and Viet Nam have such personal status laws based on religion or ethnicity. In case of divorce, for instance, personal status laws for Muslims in Brunei Darussalam, Indonesia, Malaysia and the Philippines separate legal guardianship, which is granted to the father, from custody, which is typically granted to the mother up to a certain age. As such, these laws maintain the gendered division of family responsibilities, confirming the father’s authority to decide and the mother’s role as a care provider. Yet, there is a push towards reducing gender inequalities in the region in recent years. All countries but Brunei Darussalam have passed policy frameworks or national action plans to that end, in particular since 2019. These plans and frameworks in particular focus on reducing violence against women, eliminating child marriage and improving women’s labour rights (OECD, 2024[88]).

In some ASEAN countries, women are more likely to face discrimination if they do not live in accordance with the traditional view of the family consisting of a married heterosexual couple with children. Women not living up to societal expectations emphasising this ideal family image are often viewed as less stable or reliable. In Indonesia, for instance, there is a persisting social stigma against divorced and widowed women (Parker, Riyani and Nolan, 2016[89]), and single parents in Singapore have faced similar stigmatisation in the past (Wong et al., 2004[90]), resulting in the marginalisation of these women.

Drastically reducing gender inequality requires a societal transformation of both women’s and men’s views on which behaviours and types of paid or unpaid work are appropriate for men and women to execute. Employment choices not only depend on what individual men and women, as well as their (potential) employers, think, but also on expectations of family members, the community and the wider society – or at least the individuals’ perceptions of the expectations of the people around them (OECD, 2024[88]). Broad information and communication campaigns on the benefits for a more equal sharing of employment and care tasks across genders, including informing men about how doing so can improve their well-being and mental health, can contribute to instigating such a change. Wide sections of civil society should be involved to successfully realise this societal transformation, including advocacy groups and key community members.

Labour regulations can contribute to the societal transformation of the gendered division of labour. Ensuring equal remuneration for work “of equal value”, as was introduced in Thailand’s labour protection laws with the possibility to punish discriminating employers in 2019, is an important principle in eliminating gender discrimination in the workplace (OECD, 2024[88]). This requires not just that two workers in the same job are paid the same wage, but that two workers using the same skills and generating the same value for the economy are remunerated equally – even if they are employed in different sectors. Even if difficult to enforce in practice, enshrining this principle in the law sends an important signal on a government’s commitment to improve gender equality in the labour market. In addition, providing flexible working conditions for people with care responsibilities would facilitate combining paid work and care provision.

Formal long-term care (LTC) services for older people are underdeveloped in most ASEAN countries, which means that families, and in particular women, often have to step in to provide long-term care (Addati, Cattaneo and Pozzan, 2022[91]; OECD, 2024[88]). Singapore is the only country in the region with a comprehensive LTC system, funded from social insurance contributions while targeted support is financed by taxes. In all other ASEAN countries, the family is the primary LTC provider, with state support often only available in situations of dire need: for poor people, those who are completely bedridden or who have been neglected by their families. Brunei Darussalam provides free home care services only to bedridden people, a targeted LTC benefit and a benefit to family caregivers conditional on cohabitating with the care receiver. Malaysia, the Philippines, Thailand and Viet Nam only support LTC service provision on a targeted basis, and Indonesia does so for bedridden people. Myanmar in principle has a universal scheme providing free access to LTC, at home as well as in residential and day-care institutions, but in practice families remain the primary providers of LTC. Cambodia, Indonesia and Lao PDR have no formal system of LTC provision. Indonesia, the Philippines and Thailand have LTC institutions for older people who have been neglected by their families.

In all ASEAN countries, the law stipulates that the family has a certain responsibility in providing care for relatives (Addati, Cattaneo and Pozzan, 2022[91]; OECD, 2024[88]). In Cambodia, children have a constitutional duty “to take good care of their elderly parents according to Khmer traditions”. However, the Cambodian Government does recognise that population ageing and migration will put familial care provision under pressure and therefore seeks to develop community-care and caregiver-support programmes (Royal Government of Cambodia, 2017[92]). Similarly, Indonesian law prescribes that an adult child has to look after their parents and other family members in straight lineage (e.g. grandparents) if they are in need of care;26 and Vietnamese law obliges adult children and grandchildren to care for their parents or grandparents if they are sick, old or disabled, although this responsibility can be delegated with the consent of the older person.27 Singapore has a legal obligation to care for dependent parents, including the co-payment of care fees, although it does provide tax relief to people providing care to older dependents under the Parent Relief scheme, in particular if they live in the same household, with the explicit goal “to promote filial piety”.28 Family-care provision is further encouraged through incentivising people to purchase a home close to their child or parent.29 Similar obligations for family members to provide long-term care exist in a few OECD countries. In Estonia and Portugal, for instance, family members are legally obliged to provide care to a person with long-term care needs (Hoyer and Reich, 2016[93]), while in Lithuania, municipalities can refuse to provide formal care to persons who could rely on family care (OECD, 2022[94]).

These legal principles are in line with strong expectations towards children to provide long-term care in ASEAN countries (Asian Development Bank, 2024[49]; 2023[57]). Over 80% of people in Indonesia, Malaysia, Myanmar, the Philippines, Singapore and Viet Nam are of the opinion that adult children have a duty to provide LTC to their parents. Children complying with these expectations report higher happiness levels despite the intensity of care provision in Viet Nam, which may further underline wide societal support for this opinion, although the causal direction of the effect remains unclear (Mai and Le, 2024[95]). Yet, there appears to be a generational shift in long-term care expectations as younger generations in Indonesia, Malaysia and Viet Nam are increasingly more willing to receive and pay for professional home care for their future needs.

Women’s responsibilities in long-term care provision contribute to the “sandwich generation”: an age group of women who simultaneously care for older parents and their children – or even grandchildren. A growing share of women fall in the sandwich generation in the Philippines and Singapore (Chan, 2021[96]; Tongson, 2020[97]). However, in Southeast Asia overall, the prevalence and average duration of having to look after children and parents at the same time is projected to remain largely stable between the 1970 and 2040 birth cohorts. In most lower and middle‑income countries, by contrast, demographic evolutions are projected to reduce the occurrence of these dual care responsibilities (Alburez‐Gutierrez, Mason and Zagheni, 2021[98]).

Caregiving can severely limit the time available for paid work. In the age group 55‑59, Singaporean family caregivers for dependent older people on average spend 36 hours per week providing care; 29 hours among people who are in employment and 47 hours among people not in employment (Gubhaju et al., 2017[99]), with the need for family-care provision likely to increase by 2030 (Chan, 2021[96]). The average number of hours spent caring increases to around 50 hours per week from age 65 onwards, as dependents’ care needs increase and people leave the labour market: in this age group, family caregivers who are still in employment on average provide 38 hours of care per week, or 55 hours per week if not combined with employment. In Viet Nam, giving care to older people is a time‑intensive occupation as well. Family caregivers on average spend 22 hours per week on household tasks, 17 hours on personal care and another 12 hours providing mobility support, or a total of 51 hours per week (Laguna, 2022[100]). The lower amount of time available results in a deterioration of women’s income position: in Thailand, women lose about 30% of their potential earnings due to unpaid care burden (Asian Development Bank, 2024[49]).

The gendered division of care and household work translates into women spending more time performing unpaid work compared to men. Women spend around three hours per day performing unpaid care and domestic work in Cambodia, Lao PDR and Thailand, and even around 4.5 hours in Malaysia (Figure 3.16). On average across these countries, men spend about three times less time on unpaid work, although variation is bigger, ranging from 0.3 hours per day in Cambodia to 2.4 hours in Lao PDR. Hence, unpaid work is distributed most equally in Lao PDR where women perform 57% of unpaid care and domestic work, whereas in in Malaysia and Thailand they perform 76% and in Cambodia even 91% of the unpaid work. Cambodia’s position illustrates that gender equality in legislation and in social norms do not necessarily coincide: the country’s low score in the low overall SIGI score on discrimination in the family (see above) may reflect low gender discrimination in family and inheritance laws, whereas time‑use data seem to indicate a strikingly unequal distribution of unpaid work across genders. Unpaid work reduces the time available for women to perform paid work or develop their human capital, which in turn contributes to women being more likely to be enrolled in low-paid work and/or work part-time.

Family caregiving can reduce people’s overall feeling of well-being. Not only can care provision reduce social networks (see above), LTC provision impacts the physical and mental health of care providers as well. Lifting people or providing support in homes that are insufficiently equipped for a person with mobility problems are risks to the physical health of care workers, whereas time pressure and verbal abuse contribute to mental-health risks (OECD, 2023[101]).

Developing formal childcare and LTC can contribute to strengthening women’s labour market participation. As care work is largely performed by women, this would provide women more economic security, both in terms of labour protection and social-security entitlements. At the same time, it would relieve other women from some caregiving responsibilities, facilitating their integration in the labour market. Formalisation of care work would benefit care recipients through improved care quality, in particular if training courses or certification of acquired competences are introduced in the formalisation process, and could in addition attract more men into care work (OECD, 2024[88]).

Formalisation of LTC is important to ensure care needs are met in an ageing society. Declining fertility and increasing internal and international migration (International Organization for Migration, 2021[102]) resulting in older people and their children living further apart, will limit the availability of family care in the future. In absence of a proficient LTC system, a decline in the number of children available to take up caregiving responsibilities is likely to not only result in more older people facing unmet needs, but also to increase pressure on the available children and on hospitals. A lack of affordable LTC services hence comes at a cost of lower labour market participation and reduced working hours in particular among women in their 50s and 60s, and of overburdening healthcare services as people with LTC needs who do not receive appropriate care often end up occupying hospital beds.

Undeclared employment is common in LTC, even in some higher-income countries (OECD, 2023[101]). In absence of formal LTC services, families often rely on undeclared live‑in care workers, migrants usually, to provide assistance to older people with care needs. As the work largely takes place in people’s homes, it is difficult to protect workers from poor working conditions or abuse through labour inspection or unionisation. Training programmes for LTC workers, as well as well-designed visa schemes, can help incentivise both families and care workers themselves to formally register the care worker and improve worker protection. Moreover, through training programmes and certification, family carers’ skills can be recognised, which would facilitate becoming a formal long-term caregiver (Asian Development Bank, 2024[49]).

Universal access to LTC services is aligned with UN commitments including the Sustainable Development Goal on universal health coverage and the Convention on the Rights of Persons with Disabilities (WHO, 2024[103]). This could for instance be achieved through expanding existing universal health coverage programmes to also include basic LTC services as is being done in China (WHO, 2024[104]). Basic LTC packages often focus on activities of daily living (ADL) and in particular the delivery of personal care, such as bathing, dressing and toilet visits. Assistance with instrumental activities of daily living (IADL), such as shopping, cooking and cleaning, can have a preventive function, however, for instance in terms of early detection of ADL limitations (WHO, 2024[105]). Alternatively, a targeted approach can allow for a more efficient use of available public resources if the means-test is effective at identifying people without the means to finance their own care needs.

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