China and India, neighboring countries and the undisputed global population giants, boast two of the world’s most rapidly growing economies.

With 1 billion-plus citizens and striking regional variation, both countries are racing to find policy solutions to two hallmarks of the demographic transformation under way in Asia: larger numbers of elderly citizens and decreasing fertility rates. How China and India resolve the challenge of supporting their elderly while maintaining economic advancement despite shrinking working-age cohorts will strongly shape their future and may provide valuable lessons for other developing countries, which will face similar issues in the coming decades.

This March, Stanford’s Asia Health Policy Program (AHPP) partnered with Harvard University to bring together experts from the United States and Asia for a results-oriented policy dialogue on the economic implications of aging in China and India. AHPP director Karen Eggleston describes the key issues in each country, and research findings presented during the conference, ranging from initial policy steps to the effects of gender inequality on aging.

Both China and India are rapidly developing countries with populations of over 1 billion. But there are also differences in the demographic landscape of each country, including the fact that China’s population is aging more rapidly. What can these countries learn from one another, and, what can we learn from their experience?

Since population aging shapes the future of almost everyone on this planet, and countries have experienced the process at different times and rates, there indeed is much that can be learned from other countries’ experiences. High-income countries began this demographic transition earlier. India and China are distinctive in that they together account for more than 1 in 3 people in the world, and are still developing countries. As a result of declining fertility, increasing life expectancy, and the progression of large cohorts to the older ages, both of them, like all other countries, have aging populations. 

The proportion of China’s population aged 60 and older is projected to grow from 13 percent today to 34 percent in 2050, as David Bloom and I noted in our call for papers for this conference. India’s 60-plus share is expected to increase from 8 percent to 19 percent over the same period. China’s total fertility rate began to fall much earlier and faster than India’s, and its life expectancy began to rise much earlier. As a result, China’s ratio of working-age to dependent population has recently peaked and will decline. In India, the ratio is still rising, and it will be several decades before the effect of population aging in lowering the ratio will be felt in a major way.

One might categorize India as “young Asia” and China as “maturing Asia,” as Sang-Hyop Lee of the University of Hawaii did in research presented at the conference. The challenge for India then is how to make the most of its current large cohorts in the working ages.

Demographic change can lead to a demographic dividend—a one-time boost in income per capita—when the working-age share of the population is relatively high, if that population is productively employed. Both countries will need to establish sustainable systems of old-age support to relieve the strains on the family support system, with that need more urgent in China. 

What are some of the policy steps the governments of China and India have already taken to help their countries adapt to the aging phenomenon? Why will they need to do more?

Both governments have begun to put in place policies to address various aspects of population aging, but both have considerable room to do more.

For example, health coverage remains limited in India; and although health coverage has improved dramatically in China, many people with chronic diseases like high blood pressure remain undiagnosed and untreated. India does not have health insurance or other medical cover for most of the population, although ambitious policy goals for universal coverage are being discussed. Indrani Gupta of the Institute of Economic Growth in Delhi shared research suggesting that fear of impoverishment from health expenditure results in the elderly in India foregoing medical care.

Some policies to improve old-age support, such as China’s new rural pension system, are so recent that little is known about their long-term effectiveness. During the conference, Bei Lu of the University of New South Wales and her colleagues discussed recommendations for strengthening China’s pension system.

The Brookings Institution’s Feng Wang and his colleagues shared new estimates of consumption and income by age in China. Their estimates for 2007 indicate a remarkably constant level of consumption across generations in China. On the one hand, this result could be considered a remarkable feat of intergenerational support, as Ronald Lee of University of California, Berkeley, pointed out at the conference. Even though the current elderly had much lower standards of living when they were working and limited opportunities for savings and investment, he said, they are nevertheless sharing in the higher level of consumption that their children and grandchildren are now enjoying.

On the other hand, relatively flat consumption by age could indicate a policy gap. National Transfer Account estimates show that consumption is fairly flat into old age for both China and India, compared to steeply increasing consumption by age in many higher-income countries like Japan or the United States, driven by large healthcare expenditures. The consumption profile by age in China and India suggests that many older adults may be foregoing the kind of medical care that those in higher-income countries regularly receive.

Another important policy arena is family planning. Demographers have long argued for China to relax its family planning policies. It is unclear whether the recent announcement of the merger of China’s Ministry of Health and its Family Planning Commission might bode relaxation (or even abandonment) of the unpopular “one child policy.”  

Indeed, almost all policies are inter-related with the phenomenon of population aging to some extent. For example, the current generation’s educational investments, financial burden, and labor market opportunities can benefit from improvements in old-age support and changes in the traditional pattern of support through co-residence (as research presented by Anjini Kochar and Ang Sun discussed for India and China, respectively). One interesting paper even explored the relationship between climate change and nutrient intake. Kimberly Singer Babiarz, Jeremy Goldhaber-Fiebert, and colleagues argue that as the Indian government develops policies to address climate change, it is important to consider how climate change will impact food insecurity—particularly through reductions in macro- and micronutrient intake—for different population groups, including the elderly.

Are there investments that can be made in childhood health and education that can help make a significant difference later?

Certainly. A growing body of evidence shows the importance of early life investments for life-long wellbeing. For example, Mark McGovern and colleagues presented research showing that early life conditions impact “frailty” in old age in China, and that size at birth in India is correlated with later health as well. As they note, investments in improved child health could have large pay-offs in terms of better health throughout the life course. Related research by David Bloom and colleagues showed how costly non-communicable diseases are for both China and India, and how some policies to prevent non-communicable diseases among children and young adults could provide large social and economic benefits. Moreover, improved educational attainment of young people can make them more productive and resilient, helping to offset the social and economic challenges associated with a smaller workforce. Some have suggested a “second demographic dividend” could arise for economies that invest sufficiently in their young people, encouraging education, savings, and investment.

What are some of the impacts of gender inequality on aging?

Gender inequality and population aging interact in several ways in India and China; these interactions were an important sub-theme for the conference discussions. While it is complicated to fully capture the resource allocations and power dynamics within households, new datasets are increasingly providing a window into these important dimensions. For example, research presented by Ajah Majal and colleagues using the Longitudinal Aging Study in India (LASI) data suggested the need to focus on female elderly and elderly residents in poorer states, and to use multi-dimensional approaches to assessing wellbeing. Similarly, Jinkook Lee and James P. Smith of the RAND Corporation use the LASI to study gender differences in late-life cognition. They note that greater access to education among girls and women could significantly reduce gender disparities in India, and that greater access to education will benefit not only those who receive the education directly, but also their parents and children.

David Weir of the University of Michigan and colleagues combined data from numerous sources to document large gender differences in human capital and in cognitive capacity of individuals that are now over age 50 in China and India. Elderly women lag particularly in cognitive capacities involving numbers, and in India more so than China, while gender gaps go beyond education.

China has made dramatic progress in reducing gender disparity in education, as James Smith emphasized. It is quite common for illiterate grandmothers—who themselves had many fewer opportunities than men—to have college-educated granddaughters with educational opportunities comparable to that of young men. Of course, both China and India are large and diverse countries, with significant regional differences in son preference and gender disparities, as well as large income and wealth disparities for both genders.

Revised papers from the conference will be considered for a special issue of a new academic periodical, the Journal of the Economics of Aging. The special issue will be co-edited by David Bloom (co-editor of the Journal of the Economics of Aging and professor of economics and demography at the Harvard School of Public Health) and Karen Eggleston (director, Asia Health Policy Program, Shorenstein Asia-Pacific Research Center, Stanford University).

Image: A Kashmiri boy touches the hand of his grandmother, November 2005. (REUTERS/Kimimasa Mayama Pictures)

Image: An elderly couple dances in a public park in Kunming, July 2005. (Flickr user maverick2003)

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Triyana will focus on analyzing the effects of rural-urban migration on children’s health outcomes in China and Indonesia, contributing valuable insight toward Shorenstein APARC’s research initiative on demographic change in Asia.

Currently an Indonesia Research Fellow at the Ash Center for Democratic Governance and Innovation at Harvard University, Triyana is also completing her doctoral degree from the Harris School of Public Policy at the University of Chicago. She holds a BA and an MA in economics, and a BS in mathematics, all from the University of Chicago.

Mariano-Florentino Cuéllar, a Stanford law professor and expert on administrative law and governance, public organizations, and transnational security, will lead the university’s Freeman Spogli Institute for International Studies.

The announcement was made in Feb. 11 by Provost John Etchemendy and Ann Arvin, Stanford’s vice provost and dean of research.

“Professor Cuéllar brings a remarkable breadth of experience to his new role as FSI director, which is reflected in his many achievements as a legal scholar and his work on diverse federal policy initiatives over the past decade,” Arvin said. “He is deeply committed to enhancing FSI’s academic programs and ensuring that it remains an intellectually rich environment where faculty and students can pursue important interdisciplinary and policy-relevant research.”

Known to colleagues as “Tino,” Cuéllar starts his role as FSI director on July 1.

Cuéllar has been co-director of FSI’s Center for International Security and Cooperation (CISAC) since 2011, and has served in the Clinton and Obama administrations. In his role as FSI director, he’ll oversee 11 research centers and programs – including CISAC – along with a variety of undergraduate and graduate education initiatives on international affairs.  His move to the institute's helm will be marked by a commitment to build on FSI’s interdisciplinary approach to solving some of the world’s biggest problems.

“I am deeply honored to have been asked to lead FSI. The institute is in a unique position to help address some of our most pressing international challenges, in areas such as governance and development, health, technology, and security,” Cuéllar said. “FSI’s culture embodies the best of Stanford – a commitment to rigorous research, training leaders and engaging with the world – and excels at bringing together accomplished scholars from different disciplines.”

Cuéllar, 40, is a senior fellow at FSI and the Stanley Morrison Professor of Law at the law school, where he will continue to teach and conduct research. He succeeds Gerhard Casper, Stanford’s ninth president and a senior fellow at FSI.

“We are deeply indebted to former President Casper for accomplishing so much as FSI director this year and for overseeing the transition to new leadership so effectively,” Arvin said.

Casper was appointed to direct the institute for one year following the departure of Coit D. Blacker, who led FSI from 2003 to 2012 and oversaw significant growth in faculty appointments and research.

Casper, who chaired the search for a new director, said Cuéllar has a “profound understanding of institutions and policy issues, both nationally and internationally.”

“Stanford is very fortunate to have persuaded Tino to become director of the Freeman Spogli Institute for International Studies,” Casper said. “He will not only be an outstanding fiduciary of the institute, but with his considerable imagination, energy, and tenacity will develop collaborative and multidisciplinary approaches to problem-solving.”

Cuéllar – who did undergraduate work at Harvard, earned his law degree from Yale and received his PhD in political science at Stanford in 2000 – has had an extensive public service record since he began teaching at Stanford Law School in 2001.

Taking a leave of absence from Stanford during 2009 and 2010, he worked as special assistant to the president for justice and regulatory policy at the White House, where his responsibilities included justice and public safety, public health policy, borders and immigration, and regulatory reform.  Earlier, he co-chaired the presidential transition team responsible for immigration.

After returning to Stanford, he accepted a presidential appointment to the Council of the Administrative Conference of the United States, a nonpartisan agency charged with recommending improvements in the efficiency and fairness of federal regulatory programs.

Cuéllar also worked in the Treasury Department during the Clinton administration, focusing on fighting financial crime, improving border coordination and enhancing anti-corruption measures.

Since his appointment as co-director of CISAC, Cuéllar worked to expand the center’s agenda while continuing its strong focus on arms control, nuclear security and counterterrorism. During Cuéllar’s tenure, the center launched new projects on cybsersecurity, migration and refugees, as well as violence and governance in Latin America. CISAC also added six fellowships; recruited new faculty affiliates from engineering, medicine, and the social sciences; and forged ties with academic units across campus.

He said his focus as FSI’s director will be to strengthen the institute’s centers and programs and enhance its contributions to graduate education while fostering collaboration among faculty with varying academic backgrounds.

“FSI has much to contribute through its existing research centers and education programs,” he said. “But we will also need to forge new initiatives cutting across existing programs in order to understand more fully the complex risks and relationships shaping our world.”

In addition to Casper, the members of the search committee were Michael H. Armacost, Francis Fukuyama, Philip W. Halperin, David Holloway, Rosamond L. Naylor, Douglas K. Owens, and Elisabeth Paté-Cornell.