Chinese written by Xinwei Liu
English written by Charles Qin

In 1999, ten per cent of the national population was categorized as elderly – 60 years or over. China had entered into what is internationally recognised as an ageing society.

Most developed countries have gone through either “ageing during wealth accumulation” or “ageing after wealth accumulation”, however the China of 1999 had a per capita GDP of only 840 USD. China has “aged first without wealth accumulation”!

In recent years the ageing of China’s society has intensified. At the same time, alongside ageing there have emerged another “four features” – extended life expectancy, higher-needs ageing, empty-nest ageing, and low birth rate ageing – and the problem is growing in severity. This has added a new degree of difficulty in approaching the ageing problem.

As the China National Committee on Ageing has calculated, there has been rapid growth in the number of people 80 years and older nationally, about double the rate of increase of the elderly population in general, and it is forecast that by 2050 one person out of every five will be aged 80 or more.

At the same time, there has been an increase in the number of “empty nesting” elderly. A survey by China Research Center on Ageing indicates that nearly one half of elderly people in urban areas nationally no longer live with their children. But it is in the villages – due to the youthful labour force leaving in large numbers for work opportunities – that the “empty nesting phenomenon” has become even more severe for the elderly.

In addition, lopsidedness in the degree of ageing experienced in cities compared with rural areas has become extremely pronounced. The level at which ageing has been occurring in rural areas far exceeds that of cities. The proportion of the elderly in villages makes up 70 per cent of the general national elderly population, and the degree of ageing for villagers outstrips that of cities and towns by 1.24 percentage points. It is forecast that this kind of lopsided situation will continue unabated until 2040.

In 2015, the results of the Fourth Sample Survey on The Living Conditions of China’s Urban and Rural Older Persons indicates that China has an elderly population of over 200 million people aged 60 or over, for which there is a breakthrough figure of 100 million elderly empty nesters as well as 24 million of a very advanced age, 35 million partially or wholly disabled elderly, and 23 million who are impoverished and/or on low incomes… “The silver-haired tide” is proving a shock to China’s economy, society, culture, and families.

People who are at an advanced age are people who need support. To have “good health”, “ample funds in reserve”, “a place to experience suitable aged care”, “family to keep you company” and “carers in sickness” form the five major essential prerequisites to aged care.

Relative to the five major essentials, the three problems of greatest concern to China’s elderly are: “insufficient funds to see a doctor”; “a problematic aged care social security system”; and “no one to look after you when you’re sick or unable to take care of yourself”.

Alongside the increasing and mutually overlapping disparities between city, countryside and regions, and incomes interwoven with economy and society, so too have restrictions been imposed by limitations over such areas as the level of development, capital investment, and institutional design adding a new level of difficulty when faced with Chinese-style aged care. Against such steep challenges in aged care there exists an immense social security fault line in the establishment of China’s aged care social security system that falls way behind in their aged care servicing capabilities and inability to meet the demands of the rapid increase in ageing. Caring for the aged has become an extremely pronounced social problem in today’s China as well as for China of the future.

Where shall China’s elderly go to receive care?
Do China’s elderly have enough money for care?
Who shall take care of China’s elderly?

No Place to Be Cared for 

For a person now elderly, it is hard to avoid the likely arrival of a day of sickness or personal incapacity. Where to find someone to look after you as well as an aged care location that you find personally satisfactory has become an issue of concern to many people. For the China of today, whether it be investment into community-based home aged care or the number of beds per thousand people in aged care institutions, they are still playing catch up and falling far short of satisfying the requirements of a rapidly ageing society.

In the last few decades, the nursing home has become the aged care organisation of default in Chinese society, having once been commonplace in first tier towns and cities. However, in recent years, this type of traditional aged care institution has suffered major setbacks due to a severe lack of investment, particularly in the gradual disappearance of aged carefacilities at the grassroots level. For the publicly-run aged care institutions that still survive in large and medium-sized cities, at present it is actually common to find it difficult to secure a bed, and in some cities those elderly seeking to register with welfare organisations and nursing homes have already found themselves in a queue several years long.

However, at the same time, the “Research Report into the Development of China’s Aged Care Institutions” published by the China Research Center on Ageing has also indicated that the overall vacancy rate for China’s aged care facilities at present is relatively high, with a national average of 48%.

On the one side, we see a relative shortage of resources in “a bed being hard to find”, whereas on the other resources are being wasted in an absolute sense via the high vacancy rate. How could such a paradoxical situation exist?

For historical reasons and given traditional notions of aged care, the traditional significance of China’s aged care institutions as the final port of call in society’s aged care system was not to provide all elderly people with universal aged care services but to satisfy the fixed demands of particular groups. The aged care organisations among these that were founded by government investment were first tasked with the function of meeting a “safety net”, that is, to provide the most basic of aged care services to those groups most beset by difficulties, lacking the Five Guarantees:

proper food, clothing, medical care, housing and funeral expenses, and those who had lost their source of income as well as basic protections such as no insurance, lost capacity or suffering dementia, and those who were minimally provided for.

However, along with social and economic development, so there are limited numbers of elderly people who fall below the “safety net”, and should the original criteria be maintained then this would lead to massive vacancies; however, should the criteria of entry only be “male and having attained 60 years, female and having attained 55 years”, then this would immediately cause issues in the supply of beds.

In the course of supporting the normal and healthy development of aged care institutions, the use of public resources to the greatest extent possible in releasing more bed places to more elderly groups in need is a manifest and clear trend.

The traditional method of caring for the aged in China’s villages has been a family-style reliance on caretaking via children. However, as more and more young people have left in search of work, despite wanting to assist in caretaking they have been unable to do so, hence this kind of traditional method of aged care has been subject to constant deterioration and virtual collapse. Today, a common approach to aged care in Chinese villages for those elderly left at home is simply “to look after the house” and “look after the grandchildren”. This is an extremely pronounced issue being faced in the Chinese countryside. Amongst China’s more than 100 million elderly empty nesters, the vast majority are these elderly people “focusing on two things” and living in vast and open villages, where they have no choice but to experience “aged care” in their own homes.

“Focusing on the house and grandchildren” is the basic aged care situation for the elderly in China’s villages, and that’s it. In comparison with the cities, investment into aged care in the countryside is even more insignificant, and facilities and aged care services are insufficient in the extreme with sites for elderly activities few in number to the point of being essentially insignificant, and where to have a few chess or card tables and an activity room can be considered a luxury.7

No Money for Aged Care

When developed countries advance into being ageing societies, their per capita GDP will basically range from 5,000 USD to 10,000 USD, reaching around 20,000 USD on average. In 2008, China’s per capita GDP also went past 3000 USD, a shortfall that does not seem very large. The genuine disparity, however, is that gross wages and salaries only accounts for around 13% of GDP, approximately a quarter of the average world level, and one can imagine what the individual aged care capabilities will be like for labourers who receive very low wages when their elderly years arrive.

Irrespective of the fact that today’s Chinese people possess enormous amounts of personal savings, nevertheless, against heavy pressure from the three great mountains of education, housing and medicine, this is in reality a flimsy bulwark. The reality that a person falling ill is capable of plunging a family into financial ruin has set most families to instinctively relegate aged care to the last of their lifestyle considerations. Further, due to the lack of safeguards, one dares not put what remains into investment and consumption. Due to a family planning policy that has continued for more than 30 years, creating a Chinese society today composed of middle-aged and young only children, there is, on the one hand, a financial burden on two only children providing for four elderly people – a burden that a typical small family is unable to bear; and on the other hand, significant numbers of “boomerang kids” in society, who despite not being young any more, may not want to work hard and may be unemployed and still at home, or who have a meagre income insufficient for much spending and who are still reliant on their parents to pick up the tab for their life. Under this kind of pressure, for the traditional Chinese person, most can only relegate their own aged care expenses to the bottom of the pile in family planning and the result is easily envisaged.

The fact that there are vagaries and vicissitudes in life needs no further account. Many Chinese people do not have aged care or medical insurance, and even if they do have insurance, the majority are not knowledgeable about its contents. Added is the reality that medical insurance is still unable to provide full protection, such as not covering imported medicines and some medical equipment and materials, as well as differences in the policies in different jurisdictions, with the more sophisticated allowing for the claiming of medicines for chronic diseases, but with some forcing the elderly person to bear the cost themselves, so a significant amount of lifestyle pressure is created for the elderly and infirm.

In the past, upon retirement people would be aware of how much retirement funding they could receive every month on a fixed basis and have this assurance in their minds. However, the calculation of aged care insurance is particularly complicated, distinguishing between what is socially pooled from the individual account, and there is no final assurance in people’s minds as to how much money can be attained after retirement. In comparison to those who are employed, the income of retirees over these several decades will manifest a consistent downward trajectory, and in terms of those retired and those not yet retired, some degree of anxiety will be experienced when this type of situation occurs.

The reality is worse in the villages. For those elderly Chinese living in rural communities, their labour capabilities are a fundamental backbone to their source of income, and hence, the vast majority of China’s farmers will work until they can “work no more”. As soon as the elderly person loses their labouring capabilities, they will be without a source of income.

In 2009, China’s New Rural Medical Security System begun its national pilot implementation, and the basic aged care pension was set at ¥55 per person per month. For many elderly villagers who have lost their capacity for labour, these few dozen dollars of pension money is their only source of income every month. Several years have passed, and although the New Rural Medical Security System’s coverage is constantly expanding, the pension remains the same. If the aged care spending capabilities of the elderly cannot be strengthened, so too the development of the aged care market will lack fundamental drive.

No One to Care for the Elderly

Thirty-five years ago, China’s ratio of adults capable of caring for the elderly to elderly people was 6 to 1. However, in accordance with the population trends of today, in another 35 years this ratio will decline sharply to 1 to 2, and this will, with a relativereduction in labour capacity alongside an ageing population trend, utterly overturn traditional modes of elderly care.

Traditionally, the vast majority of Chinese people relied on their children to take care of them in their senior years. However, today’s China, with a family structure of two single children and four elderly people, plus the immense pressures of life and work, has seen many born in the 1980s honestly confessing that they are unable to take on the task of caring for their parents. It is this kind of social reality that has determined that the elderly care issue in China today and tomorrow cannot solely rely on home-based care, but must gradually see a transition into care by society, that is, to transition from a mainstay of the family taking responsibility to one of national or social responsibility, and to find a resolution by way of social services. However, the gap in current social welfare systems and policy systems has led to an intensification of the caretaking burden. At the same time, while facility and funding difficulties exist in the socialisation of aged care in China, another major
problem must be dealt with – labour.

For care givers, the monthly salary for a stay-at-home nanny is ¥10,000, but for an aged care assistant it would only be ¥1,000 or 2,000. This kind of income gap has caused personnel shortages in aged care facilities in China today, posing another challenge.

There is also career discrimination. A cynical view would have it that an aged care nurse is there to serve the elderly person as they eat, drink, defecate and urinate, and that it is the kind of job for those of lowly status. It is dirty, tiring, difficult, and poorly paid of course, and at times there will be difficult and odd elderly people encountered who shall prove hard to serve. For a generation of single children in the prime of their lives, few would adopt this job as their chosen career path. Even if advanced to middle age, and unless absolutely forced, most people would not give priority to this type of work, and there is an extremely low level of desire to pursue such a career.

Even though organisations are putting some effort into raising pay, many people are still unwilling to consider this industry, and even if they are compelled to enter it, they will not do so for very long, choosing at the end to leave.

By regulation of China’s Ministry of Civil Affairs, the ratio of aged care assistants to elderly people should be 1 to 3 in aged care institutions. In reality, the number of organisations that are able to meet the ratio is minimal.

For the ratio of care personnel to elderly people to hold at 1 to 5 or at 1 to 6 is already a case of “adequate staffing”, and there are aged care institutions where the ratio of care assistants to elderly people is as high as 1 to 10 – one care assistant must look after ten elderly people.

Statistics from China’s Ministry of Civil Affairs indicate that at the moment there are fewer than 3 million aged care facility assistants in China, a gap as high as 10 million; and among the less than 3 million personnel in the industry, over half of the personnel are aged 40 or over, with 70 per cent having a high school education or less. Aged care assistance has basically become an industry where “the elderly person cannot do it, the middle aged person is too tired to do it, and the young one does not want to do it”. “No place”, “no money” and “no one” are the three major holes in China’s aged care problems. Within it, the two gaps of “no money” and “no one” are greater.

Where is the Solution?

Vice-Chair of the China National Committee on Ageing, and Chair of the China Research Center on Ageing, Wu Yushao, believes that resolution of the difficult problems in Chinese-style aged care could proceed from four avenues:

The first is to establish a healthy system of aged care guarantees. At the core of the ageing problem is the issue of social security, the focus being that there are elderly people to care for, and the key being the establishment of a robust system for social security in aged care. The establishment of a multi-level system of social security while raising national social security standards, will also give a boost to the social security awareness of citizens at the same time and encourage citizens to purchase commercial aged care insurance, aged care housing endowments, and so on. The second is to establish a robust system that supports good health in aged care. Good health is that most desired by the elderly, whereas the overall health awareness of China’s elderly is relatively low and the picture presented of elderly health is no cause for optimism. At the same time, this also means that there is significant potential in elderly health work, particularly in health management and health promotion.

The third is the establishment of a robust aged care service system. China’s community aged care services industry is very weak. In particular, with the changes currently occurring in elderly population demographics, they possess ever higher educational levels and their requirements are ever more extensive, with more higher-level needs such as being able to make a contribution, to experience value and respect, culture and education and spiritual care, and which has imposed greater requirements on aged care services. An aged care services system with “in-home aged care at the foundation, community services as the support, and institution-based aged care as the backbone” should be established and perfected as soon as possible. The promotion of aged care institution development, the strong development of medium-tosmall scale as well as micro-scale urban aged care institutions, putting the decision-making effects of the free market to full use in the development of aged care institutions, support and guidance for foreign and domestic capital to be invested into the establishment of aged care institutions, and more expedited integration of public service resources such as in aged care, medical services, education, and rehabilitation will raise service levels in the establishment of aged care institutions.

8The fourth is to establish a robust system of social support. The excessive and even smothering love placed on the young in today’s China has become a social problem, and there is insufficient respect for the aged, which has also become a social problem. The Chinese culture of filial piety should be promoted, protecting the rights and interests of the aged, fashioning an excellent social environment respectful and honouring the elderly, and loving and helpful for the elderly. At the same time, social policies must also be modified. For example, borrowing from the “one soup bowl distance” philosophy raised by Japanese sociologists, children should be encouraged to live nearby or with their parents through the provision of favourable treatment in interest on housing loans, loan deposits, and stamp duty. Borrowing from the practices of South Korea, Germany and other similar countries, “multi-generation rooms” were designed in the government’s development of publicly oriented housing to encourage different generations to live together. Borrowing from the Singaporean government’s “three generations’ close-knit bonus” method, there could be modification in the levying of personal income tax, raising the tax threshold or lowering the amounts payable in a suitable manner for those children caring for the aged. A special system of paid aged care holiday leave could be given to those currently working with a very old or infirm elderly person at home. The establishment of a system for middle and primary school students to take part in volunteering services could be investigated to encourage the community to take part in publicly minded activities, to go to aged care facilities to look after the aged. There are many ideas to be explored.