Growing old in China in socioeconomic and epidemiological context: systematic review of social care policy for older people

Abstract

Background: From 2020 to 2050, China's population aged ≥65 years old is estimated to more than double from 172 million (12·0%) to 366 million (26·0%). Some 10 million have Alzheimer's disease and related dementias, to approach 40 million by 2050. Critically, the population is ageing fast while China is still a middle-income country.

Methods: Using official and population-level statistics, we summarise China's demographic and epidemiological trends relevant to ageing and health from 1970 to present, before examining key determinants of China's improving population health in a socioecological framework. We then explore how China is responding to the care needs of its older population by carrying out a systematic review to answer the question: 'what are the key policy challenges to China achieving an equitable nationwide long-term care system for older people?'. Databases were screened for records published between 1st June 2020 and 1st June 2022 in Mandarin Chinese or English, reflecting our focus on evidence published since introduction of China's second long-term care insurance pilot phase in 2020.

Results: Rapid economic development and improved access to education has led to widescale internal migration. Changing fertility policies and household structures also pose considerable challenges to the traditional family care model. To deal with increasing need, China has piloted 49 alternative long-term care insurance systems. Our findings from 42 studies (n = 16 in Mandarin) highlight significant challenges in the provision of quality and quantity of care which suits the preference of users, varying eligibility for long-term care insurance and an inequitable distribution of cost burden. Key recommendations include increasing salaries to attract and retain staff, introduction of mandatory financial contributions from employees and a unified standard of disability with regular assessment. Strengthening support for family caregivers and improving smart old age care capacity can also support preferences to age at home.

Conclusions: China has yet to establish a sustainable funding mechanism, standardised eligibility criteria and a high-quality service delivery system. Its long-term care insurance pilot studies provide useful lessons for other middle-income countries facing similar challenges in terms of meeting the long-term care needs of their rapidly growing older populations.

Keywords: Ageing; China; Health equity; Social care; Systematic review.

Fig. 1

Trends in standard of living and total fertility rate, China, India, UK, USA and Japan, 1970–2020 A: Gross Domestic Product per capita (constant 2015 US$) of China, India, UK, USA and Japan, 1970–2020 Source: World Development Indicators. The World Bank [5]. Footnote: GDP per capita is Gross Domestic Product divided by by mid-year population. Data are in constant 2015 US$. B: Total fertility rate for China, India, UK, USA and Japan, 1970–2019 Source: World Development Indicators. The World Bank [8]. Footnote: Total fertility rate in a specific year is the total number of children that would be born to each woman if she were to live to the end of her child-bearing years and give birth to children according to prevailing age-specific fertility rates.

Fig. 2

Population health milestones in China, 1978–2021

Fig. 3

Socioecological framework of population health Source: Adapted from Dahlgren and Whitehead, Lancet, 1991. [9] Footnote: Dotted lines between the levels represent the complex interaction of determinants. Societal factors concern social, economic, cultural and environmental conditions. Community considers the characteristics of neighbourhoods, regions, schools and the workplace while relationship refers to person-to-person interactions such as social networks and family. Individual factors concern personal characteristics, genetics, lifestyle and behavioural factors.

Fig. 4

Chinese rural and urban populations, 1953–2020 Source: National Bureau of Statistics. Bulletin of the Seventh National Population Census (No.7): Urban and Rural population and the Floating Population. 2021 [85].

Fig. 5

Household composition in China, 1990–2010, percentage of total Source: Hu et al. Chin J Sociol. 2015. [93] Footnote: Household composition is defined as individuals living together who may or may not be related by blood or marriage. A one-generation household is defined as a single-person household or only-couple household. A two-generation household is a household of parents and unmarried children, a single parent and unmarried children, a separated parent and unmarried children, parents and married children, or grandparents and grandchildren. A three-generation household constitutes elderly, children and grandchildren.

Fig. 6

Systematic review flow diagram and search terms