Department of Psychogeriatrics, Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, WHO Collaborative Research and Training Center on Mental Disorder, Shanghai Mental Health Research Institute, Shanghai, China.
Department of Psychogeriatrics, Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, WHO Collaborative Research and Training Center on Mental Disorder, Shanghai Mental Health Research Institute, Shanghai, China.
Address correspondence to Joseph Henry Flaherty, MD, Department of Internal Medicine & Division of Geriatrics, Saint Louis University School of Medicine, and the Geriatric Research, Education and Clinical Center, St. Louis VA Medical Center, St. Louis, Missouri, 1402 S. Grand Blvd, Room M238, St. Louis, MO 63104. Email: Flahertyinchina@yahoo.com
This article examines the changing demographics of China, with particular attention paid to the effect of the one-child policy in relation to long-term care of older people. It also examines the current state of health care for older people. Long-term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries.
Geriatric departments in university-based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics
Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower-and middle-class Chinese and have increased more quickly than has the standard of living in the past 20 years.
Family and community support for older people is strong in China. Some older people have one-to-one care from a baomu (literally “protection” (bao) “mother” (mu)), a type of live-in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.
Once called the “sleeping giant,” because of the potential of its economy, China now faces a different kind of growth: its aging population. According to a 1982 census, 7.6% of its population of one billion was aged 60 and older. Today, more than 10% of its 1.3 billion citizens are in this category (Table 1).1 According to the United Nations, an aging society is a society with at least 7% of its population aged 65 and older. China reached 7.6% in September 2005. What does this mean for China, and what does China's aging mean for the world, if currently one of every five older people on earth is Chinese?2 In an attempt to address some of the major problems facing China with its aging population, this article examines available demographic information, published literature, and some observations by one of the authors (JF) during a 1-year sabbatical to China. It includes his experiences in hospitals, outpatient clinics, and nursing homes (NHs) in three major cities: Beijing, Shanghai, and Chengdu—all cities with populations of more than 10 million. His visits took place from October 2005 through September 2006.
Table 1. China: Population, Changing Demographics, and Healthcare Statistics1
Nursing home (NH)-level care was chosen as a descriptor, because, in developed countries, older persons who require a level of care typically seen in NHs, primarily having to do with assistance of daily activities or related to dementia, whether they are cared for at home or in facilities, have posed great challenges to the healthcare systems. “NH-level care” is descriptive and does not necessarily imply the need for more facilities.
The number used for 2030, “336,000,000” should be accurate, because those who are in this category (aged ≥60) have already been born. Thus the prediction is based only on crude mortality rates and not estimates of birth rates or population growth.3
The number requiring NH-level care was based on a 5% estimate that is seen in most developed countries.
For comparison, in the United States, general government expenditure on health as a percentage of total expenditure on health is 44.6%, private expenditure on health as percentage of total expenditure on health is 55.4%, and out-of-pocket expenditure on health as percentage of private expenditure on health is 24.3%.
¶ Includes private health insurance and out-of-pocket expenditure.
Population aged ≥60 (2006)
Population aged ≥60 requiring NH-level care* (estimated 5% of 130 million)
Population aged ≥60 requiring NH-level care without a caregiver (estimated 5% of 6.5 million)
2030 projected population aged ≥60 requiring NH level care‡ (estimated 5% of 336 million)
2030 projected population aged ≥60 requiring NH level care without a caregiver under various scenarios
50% do not have caregiver (50% of 16.8 million)
Change in 25 years, % (325,000→8.4 million)
25% do not have caregiver (25% of 16.8 million)
Change in 25 years, % (325,000→4.2 million)
10% do not have caregiver (10% of 16.8 million)
Change in 25 years, % (325,000→1.68 million)
Life expectancy at birth (2004)
Healthy life expectancy at birth (2002)
Total health expenditures, % of gross national product (2003)
General government expenditure on health, % of total expenditure on health (2003)§
Private expenditure on health, % of total expenditure on health (2003)§,¶
Out-of-pocket expenditure on health, % of private expenditure on health (2003)§
Physicians/1,000 population (2001)
Nurses/1,000 population (2001)
Community health workers/1,000 population (2001)
Hospital beds/1,000 population (2004)
Population living in rural areas, %
University-affiliated hospitals and clinics (Table 2) were chosen as the primary basis for this article for the following reasons. First, throughout China, most health care and physicians are hospital based. Second, the five major types of hospitals are university affiliated, provincial, county, community, and private. The government and most patients consider the above order to be the rank in which delivery of health care is most up to date, and the order for which trends in health care occur. NHs visited (by JF) were identified through local connections in Beijing, Shanghai, and Chengdu.
Table 2. Description of University-Affiliated Hospitals and Clinics Visited in This Study
Inpatient Beds, n
Inpatient Beds Occupied by Patients Aged ≥60, Average %
† For Shanghai Mental Health Center, Jiatong is primary affiliation, and Fudan and Tongji are secondary affiliations.
Peking University First Hospital
Beijing Medical University
Shanghai Mental Health Center
Jiaotong University (Fudan University; Tongji University)†
West China Hospital in Chengdu
HOW CHINA'S NUMBERS MAY AFFECT LONG-TERM CARE OF OLDER PEOPLE
The 4:2:1 Paradigm
The term “4:2:1” describes the future social family structure in China: four grandparents, two adult children, one grandchild. Among other things, it raises the question of whether two adult children who are married, both of whom were born in 1980s without brothers or sisters, can care for both sets of elderly parents when the two adult children themselves turn 50 in the 2030s.4,5
Few people in the world are unfamiliar with China's one-child policy, which the government introduced in 1979 under Deng Xiao Ping. Although the fertility rates of many countries have slowly changed, thus giving countries time to adapt to demographic shifts, China's change is more dramatic, because in the 1950s and 1960s, during Mao Zedong's time, fertility rates were between 5.6 and 6.3. Then, in the 1970s and 1980s, fertility declined sharply, to 2.2.6 Strict implementation of the one-child policy occurred in the mid-1980s. The effect of these policies on long-term care of older people will begin to be seen in 2030.
Table 1 shows the possible projected increase in older Chinese who will require a level of care similar to NH–level care who may not have a family member to care for them. The most important part of this calculation is the rate of change. Even in the best-case scenario, it will be more than 500%. To put this in perspective, if Beijing were to decide to build more facilities as a response, this would mean going from the approximately 300 NHs that served only 0.6% of Beijingers aged 60 and older in 1998 statistic7 to 1,500 over the next 25 years. This represents a construction rate of 48 new facilities per year.
If home care becomes part of the answer, training people to do this will become increasingly important. Although China is known for its large workforce, to train home care workers at a constantly increasing yearly rate would certainly constitute a challenge.
This rate of change will also significantly affect hospitals, which may carry the burden of care if care is not shifted to homes or facilities.
These projections, however troubling, may not be as worrisome as they seem at first. First, adults who are not married and those who are divorced may be free to care for their elderly parents. Second, the one-child policy has been loosened for farmers, for ethnic minorities, and for couples who are themselves single children. Last, one option that Chinese children are already providing for their parents who need more care is hiring a live-in maid, called a “baomu.”8 Bao in Chinese means “protection,” and mu means “mother.” These people may have some training in eldercare, but there are currently no standards. For many families who have enough income, they are affordable. Estimates of costs range from 600 to 1,000 RMB (US$75–125) per month.
Rural and Urban Populations
Despite the fact that there are many large cities in certain parts of the country, most Chinese people live in rural areas (Table 1). This may affect health care for older people for two reasons. First, rural areas are still quite poor. Average annual income of farmers, who make up the majority of rural Chinese, is less than one-third that of urbanites, which affects the ability to pay for health care.9 Second, millions of migrant workers come to the cities to try to make a living, which may leave older people behind without the traditional network of children to care for them as they age. Older persons from the rural areas or small towns sometimes come with their adult children when they move to the big cities, but only if the adult children are financially successful.
THE STATE OF HEALTH CARE FOR OLDER CHINESE
Long-term stays characterize hospital care for older Chinese. Average length of stay (LOS) was at least 2 weeks on wards with primarily cardiology patients, approximately 4 weeks on wards that cared for general medical patients, and as long as months on the psychiatric ward. Table 3 shows data on all admissions of people aged 60 and older to the Geriatric Department of Peking University First Hospital in Beijing, from November 1, 2003, to October 31, 2005. Overall, the average LOS ± standard deviation was 36.9 ± 33.6 days.10
Table 3. Average Length of Stay (LOS) and Average Total Cost per Patient According to Age Quartile at the Geriatric Department of Peking University First Hospital in Beijing from November 1, 2003 to October 31, 2005
Mean ± Standard Deviation
27.5 ± 21.4
36.4 ± 33.1
44.3 ± 39.2
52.5 ± 42.7
Total cost, US$
3,700 ± 4,500
5,000 ± 7,100
5,900 ± 6,900
6,500 ± 5,900
Hypotheses for the relatively long average LOS include expectations on the part of patients and doctors, lack of postacute care facilities, no system equivalent to the Diagnostic Related Group (DRG) system, and social factors (e.g., family caregivers who both work). During this period, 93.5% of patients were discharged home, 3.6% died in the hospital, and 2.9% were transferred to another facility.
Data from this hospital also revealed that 75.1% were male. The primary reason for this is that a major portion of patients who receive care at this hospital and other high-ranking university-affiliated hospitals are retired government officials.
Restraints were rarely used in any wards visited at any of the observed hospitals (<5%), with the exception of the psychogeriatric unit at Shanghai Mental Health Center (MHC) and the intensive care units of the other hospitals, where prevalence rates were greater than 20%. Indwelling urinary catheters were also rarely used except in the ICUs of hospitals visited, where prevalence rates were greater than 40%.
According to observation (JF), geriatric syndromes such as falls, urinary incontinence, pressure ulcers, frailty, and functional impairment seemed to be less common than seen in U.S. hospitals. Polypharmacy was more common. It could not be determined whether depression, malnutrition, and loss of function while in the hospital were less common or less commonly recognized. Delirium and dementia were uncommon in all wards at all hospitals except at Shanghai MHC.
Patients typically choose a specialist based on their own knowledge of their medical history or symptoms or at the recommendation of a nurse in the lobby of the hospital who can help with this decision. Appointments are usually not made ahead of time. Patients show up in the morning, choose the clinic they wish to attend, and buy a ticket from a ticket counter. If patients want to see the same physician every time, they still must go through this process.
Although most clinics averaged 8 to 10 patients an hour, it was the sense of “crowdedness” that made these clinics unique. Each doctor had only one office or examining room that they worked out of. It was not uncommon to see more than one patient in the room at the same time, one having just sat down at the desk and the other finishing up or having come back after his visit because of something he had forgotten or wanted to clarify. The exception to this was the psychogeriatric clinic, where usually, but not always, the door was kept shut during the entire visit.
All the clinics had the occasional “family member” visit, when a daughter or son was there to obtain prescriptions or give an update and ask a question about their mother or father.
Prescriptions were only given for 30 days at a time, without refills. Polypharmacy seems more common than in the United States. This has to do in part with the high use of traditional Chinese medications (TCM) along with the concomitant use of Western pharmaceuticals. Most physicians, although having some familiarity with TCM, often admitted that their training in this area was not adequate.
NHs in China
There are several type of NHs in China. Residents are there mostly for social reasons, for example low income and “childlessness” or not having any close relative to live with (more common in rural areas) or disability that the family is unable to support (more common in urban areas).11 NHs based on medical reasons for admission are less common but do exist. The number of these latter types of NHs is expected to grow.
Although most NHs are still government subsidized, according to a white paper published on December 12, 2006, by the State Council Information Office giving an account of what the Chinese government has done and is planning to do for their aged population, there is an “encouragement of social resources” for the following types of institutions: state-built and privately run, privately operated with government support, government subsidy, and services purchased by government. By the end of 2005, there were 39,546 institutions providing services for seniors, such as social welfare institutions for the aged, elderly people's homes, senior citizens' lodging houses, and NHs for the aged, with a total of 1.5 million beds, including 29,681 rural elderly people's homes with 895,000 beds.12 According to one source, governments at different levels have recently formulated tax exemption and financial incentive policies to encourage private investment in senior care facilities.13
That being said, the existing system accommodates only 0.8% of China's total aging population,14 far fewer than expected according to international standards. Based on numbers from the Ministry of Civil Affairs, to increase capacity even to 3%, China needs to invest at least US$200 billion.7
However, more facilities alone may not be the answer to the challenge China faces. Currently, cities are densely settled, which creates tight-knit neighborhoods. This may help with the success of part of the 11th Five-Year Plan on Aging in its attempt to “incorporate services for seniors into community development plans” and help achieve the goal that “every residential community will be required to have senior citizen service centers, senior citizen–friendly transportation facilities, and community service personnel specialized in helping senior citizens.”14
THE STATE OF GERIATRICS AS A SUBSPECIALTY: STILL YOUNG
The departments of geriatrics at the Beijing and Chengdu hospitals and the Department of Psychogeriatrics at Shanghai Mental Health Center developed within the past 1 to 2 decades, because leaders of the hospitals or universities became aware of the needs of an aging population. There are no formal geriatric fellowships or national board certifications in geriatrics as there are in more-established specialties such as cardiology and pediatrics. Directors and other physicians within these departments are specialists in other areas (e.g. cardiology, pulmonology, and psychiatry), although geriatrics departments are currently training future geriatricians, that is, residents who choose to receive their training primarily within and under the supervision of these departments. When they finish, that university or hospital will consider them to be geriatricians.
Geriatric departments have also developed out of a growing need to care for retired government officials and workers (e.g., professors of government-run universities); the majority of patients cared for within these departments come from this sector of society. It is possible that this group in China, because it has been financially more stable than other groups over the past half century, has lived longer. It is also possible that, because this group has health insurance covering hospital care, it is able to go to top-ranked hospitals, such as those affiliated with top universities.
Paying for Health Care
As has been pointed out in the past, in Europe, countries became rich before their populations became old, but in the developing world, countries' populations are growing old before they are rich. In China, as is the case in much of the developing world, the two are happening at the same time. From the beginning of the People's Republic of China in 1949 until the early 1980s, there were state-funded hospital services for urban residents, and rural people had access to subsidized health clinics run by “barefoot doctors,” who were mainly middle school graduates trained in first aid. During this time, the country's average life expectancy rose from 35 years to 68 years.15 With the economic reform that began in the 1980s, China's healthcare system moved to a fee-for-service system. It has achieved some of the success other fee-for-service systems have but is also facing many of the same challenges, such as costs of health care compared with costs of living, issues related to insurance, and incentives for providing high-tech services.9
Accompanying the further increases in life expectancy (68 years in 1981 to 71.4 years in 2000), there has been an increase in number of hospital beds (1.7 million in 1975 to 2.6 million in 2004), a rise in the number of medical professionals (3.3 million in 1975 to 5.4 million in 2004),16 and increased availability of pharmaceuticals and technology.9 What is not clear is how capable China's healthcare system will become in the care of frail older people, for whom what may be needed in addition to the above is more- and better-organized community services.
An important factor known to improve health is an increase in average income. From 1980 to 2000, average income in urban areas increased fivefold and in rural areas increased threefold, but average medical costs have increased ninefold. Insurance coverage also lags behind healthcare improvements. In 2003, only 55% of urban residents and 21% of rural residents had any health insurance. Although older Chinese currently have a good probability of having worked for some type of government office and may have some health insurance, because most of society before the policy of opening up began in 1978 was government run, the group born after 1960 are less likely to have coverage. As noted in Table 1, this is the group that will grow dramatically. If insurance coverage does not increase for them, it could have a profound effect on their families and on society. Three examples emphasize this. Out-of-pocket expenditures for healthcare costs between 1991 and 2001 increased from an average of 38.8% to 60.5% of the total healthcare costs. According to the same report, 64% of 43% of hospitalized patients who discharged themselves against medical advice did so, because they ran out of money.16 Another study found that medical spending was the number one generator of poverty for many households in rural areas.17
China is trying to address the problem of insurance. For example, since 1998, it has been expanding a basic medical insurance program financed by a payroll tax. Also, in late 2002, a policy called the New Rural Cooperative Medical System was established, under which one third of insurance premiums would each come from the central government, the provincial and lower-level governments, and the individual household.18 The program has enrolled 396 million farmers, 44.7% of the total rural population, as of September 2006. This system is meant to be available to 80% of counties by the end of 2008 and to all counties by 2010. The government will pay a maximum of 65% of medical charges a year.19
A major challenge for China is the existence of certain incentives within the healthcare system. For example, although the community- and district-level care centers and small hospitals are mostly free of charge or heavily subsidized fee for service is more common in the private and semiprivate hospital systems. In the latter, the income of hospitals is partly dependent on revenue generated from the prescribing of medications and the ordering of tests. Because most doctors in China are employed by hospitals, and part of their salary is dependent on the income of the hospital, one can understand the forces involved in increasing costs. These two forces are particularly important when considering the health care of older people, who tend to use more resources than younger groups. As seen in Table 3, costs increase with increasing age quartile.
What Is China Doing Well for Its Older Population?
Family and community support are still some of the best assets that China has. Whether it stems from some part of their cultural background such as Confucianism or is a natural part of living in a crowded country, without this “informal” support, the burden of caring for older people on the formal system would dramatically increase. Although the benefit of this aspect of Chinese culture is difficult to measure accurately, and although many believe it is changing, the more China can “use” and encourage the maintenance of this natural resource, the better off it will be in terms of caring for its growing elderly population.
The baomu system described above might be considered a luxury available only to a small percentage of the Chinese population, but this type of one-on-one care, especially if the caregiver has some training, is well worth it if it is affordable. Also, since the 4:2:1 phenomenon is unlikely to improve dramatically in the future, the baomu could become a more-important element in Chinese elder care. A challenge in preserving this part of the healthcare system is how to assist the older relatives of the baomu who, because of her employment, is less available to her own relatives. It is also not clear what the future holds for this part of the population. It is likely that the supply of service workers, such as the baomu, may not keep up with the demand for care of older people as the population pyramid changes between now and 2050 (Figure 1).
As in the West, more education in the areas of aging and care of frail older people are needed for physicians and nurses, as well as other healthcare professionals. Some of the challenges ahead include implementation of educational and training programs that teach geriatric principles and practices (e.g., learning about geriatric syndromes such as falls, polypharmacy, etc.), not just about age-related diseases common in older people (ischemic heart disease or cancer); development of certifying organizations to ensure that minimum qualifications for future geriatricians are met; and eventual transition of nongeriatricians to geriatricians as directors of the departments.
One of the greatest challenges for Chinese physicians in the care of older people, as it is around the world, is how to balance the use of technology and tests with the evidence that they may or may not improve outcomes in older people. Currently, the pressures on Chinese physicians to order tests come from patients, families, and hospital directors. What will happen when economic or other pressures mandate a limited use of resources? Will it take a crisis or near crisis (such as occurred with the severe acute respiratory syndrome epidemic) to realize that the population health dynamics related to the aging population, and the trend away from a traditional public health system to an increasingly market-based health system, cannot be sustained?
Difficult end-of-life decisions will test the cultural belief that “there is nothing better than living longer.” Is this a deep cultural belief that will not change in the future? How will this affect decisions about life-prolonging therapies? There are some informal checks and balances in place, because the majority of older Chinese still pay for a major part of their health care out of pocket. This will tend to put some limitations on the use of life-prolonging therapies. Only among the minority of well-insured older Chinese, typically retired government officials, is the use of futile care seen. If China decides to better insure more or all older Chinese, for example, a path similar to Medicare in the United States, living longer will become a factor in the financial equation.
One of the limitations of this report is that the majority of the information presented is anecdotal and related to visits to a nonrandom and perhaps nonrepresentative sample in urban areas only. As is evident in other areas of life in China, progress toward solutions to the challenges of aging in rural areas lags behind that in urban areas.
Whatever decisions China makes in the care of its aging population, these choices will have serious ramifications not only within its healthcare system, but also for its economic and social system as a whole. The growing expectation that the government should return to its role as the primary force behind China's healthcare system makes this challenge even greater.
The world is watching. Few countries in the world have faced such challenges, at the level of a potential crisis, for their elderly as China is beginning to face. Developing countries with increasing elderly populations and developed countries with already large elderly populations need new ideas and new ways to give the best to older people and help them in turn give their best back to society.
Financial Disclosure: Financial support for Dr. Flaherty's time during his year in China came from Saint Louis University in the form of a partial sabbatical.
Author Contributions: Joseph Henry Flaherty: concept and design of manuscript, interpretation of data, preparation of manuscript. Mei Lin Liu, Qunfang Ding: concept and design, acquisition of subjects and data, and preparation of manuscript. Lei Ding, Birong Dong, and Shifu Xiao: acquisition of subjects and data and preparation of manuscript. Xia Li: acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript.
Sponsor's Role: There was no financial sponsor for this manuscript.