Writing DQ 6-2

Eldercare in China: Today’s Challenges and Tomorrow’s Reform

Introduction

China’s skyrocketing population after Mao Zedong’s Cultural Revolution was the impetus for many of China’s modern policies, however, the country’s aging population is now reaching uncontrollable levels in the wake of finally controlling the country’s explosive birthrate. China currently has around 200 million citizens over the age of 65 (Nie, 2016) and that number is set to reach as high as 331 million in 2050, easily one-third of China's entire population (Glass, Gao, & Luo, 2013). Current research shows that the Chinese government is not prepared to handle this staggering figure in the future and that the country cannot even care for the elders it has now. Studies show that elder care provision today is strained by severely limited resources and support systems, as well as significant inequalities between rural and urban areas (Lu, Liu, & Piggot, 2015; Qu, Li, Liu, & Mao, 2012; Glass et al., 2013; Gustafson & Huang, 2014). This literature review explores the compounding issues surrounding China's aging population, the realities that China's elders face, the long-term care options available, and, finally, various policy recommendations.

What factors have exacerbated China’s crumbling eldercare system?

Many researchers attribute the rapidly aging population and the dearth of long-term care provision to the one-child policy enacted in 1979 which limited most families in China to having only one child (Hou & Li, 2011; Glass, Gao, & Luo, 2013; Gustafson & Huang, 2014; Lu, Liu, & Piggot, 2015). Glass et al. (2013) found that informal familial care prescribed by ancient concepts of filial piety was still the preferred method of long-term care for both younger and older generations, but drastically reduced family sizes over the past few decades has enormously increased the strain on the younger caregivers. Their results indicated that the younger generations were struggling to balance the requirements of their careers and providing adequate long-term care for their elders. Pei et al.'s (2017) research revealed that time and energy spent at work took away from eldercare provision, but without steady employment, the caregivers would not have the monetary resources needed to provide the care in the first place. Surprisingly, Glass et al. discovered that in some cases, it was the adult children who were more concerned with filial piety rather than their parents, bearing the most shame for seeking alternative options. Gui and Koropeckyj-Cox (2016) uncovered similar sentiments in their research, reporting that adult children who had delegated long-term care of their parents to a nursing home or other institution had been subjected to moral judgment by their friends, coworkers, and relatives.

In addition to the loosening bonds of filial piety, Nie (2016) reported that massive internal migration of the working age population has further strained the abilities of the caregivers to support their parents. Chen, Xu, Li, and Song's (2018) research focused on the impacts of internal migration on China's aging population. Their results found that 65% of the 245 million floating migrants in China were between the ages of 20 and 49, most of which had left their aging parents behind in towns and villages to seek out better employment opportunities. Pei et al. (2017) also found that this urbanization left staggering numbers of rural communities with only the elderly population, revealing concerns over sustainable long-term care.

What are the realities of growing old in China?

Aside from the lack of informal family care, the aging population of China faces many other harsh realities in today's society. One of the grimmest truths is the blatant social inequalities between rural and urban areas in regards to income inequality and healthcare availability, as well as the prevalence of depression and suicidal ideations. Nie (2016) proclaimed that China's rural-urban and regional inequalities were the biggest failings of the Chinese social security system. His research indicated that China's pension system was designed to first benefit civil servants and employees of state-owned enterprises, and then urban residents, with almost no pension or any other form of social security available for the rural population. He noted that rural pensions, if given out at all, are nearly 40 times lower than that of a standard pension in Beijing. Glass, Gao, and Luo (2013) claimed that the formidable income gap between urban and rural areas is due to unequal investments and developments in different areas by the government, pointing out that many of the income-related issues are entirely China's own making. Qu, Li, Liu, and Mao's (2012) research corroborated Nie's research, finding that the rural population was much less likely to retire from a government or state-owned enterprise, which would have allowed them to procure a pension. Any rural elder who did receive a pension, however, would receive a fraction of an urban resident and would be unable to obtain any other government subsidy or support.

Healthcare and health insurance are just as unevenly available across urban and rural areas, and almost as difficult to obtain for rural residents. Qu, Li, Liu, and Mao’s (2012) research found that the availability and quality of medical care were extremely lacking in comparison with urban areas and that health insurance systems were wildly different as well. Glass, Gao, and Luo (2013) encountered the same results, finding that healthcare was much more accessible and of significantly better quality in urban areas, with 49% of urban elderly able to qualify for health insurance, compared to the 12% of rural residents. Hou and Li (2011) found that China's healthcare system was structurally deficient, noting that formal systems didn't even exist in rural areas for several decades. Their results showed that even with insurance, many urban elders can't afford proper healthcare and most middle-class families are one serious illness away from abject poverty. Their research also revealed that due to medical costs, many elders all over China had a tendency to hoard medication against future possible illness. This was dangerous in of itself, they said, because the medication was often past its expiration date, posing its own health risks (Hou & Li, 2011). In rural areas, Qu et al. discovered that seeing a doctor in a rural village was so expensive and so difficult, most elderly would only consent to medical care after their pain grew unbearable, which of course meant more costly treatments. This lack of access to proper healthcare, made even more out of reach by lack of health insurance, is a seemingly insurmountable challenge to China's aging population.

In addition to financial and healthcare difficulties, China’s aging population also faces several mental health issues common in abandoned or forgotten elders. Nie (2016) found that, as with any aging society, the proportion of people suffering from mental conditions such as dementia, Alzheimer’s, and other illnesses increase dramatically with age. These mental health problems greatly increase the need for adequate care, as well as severely strain the abilities of the caregivers. He also discovered that elderly suicide was an epidemic in China, finding that victims over the age of 65 accounted for more than 44% of all suicides. He noted that, most disturbingly, the rates for rural males was three to five times higher than their urban counterparts. Mental health issues are even more severe, Song (2014) found, in families who had lost their only children, many of them have isolated themselves, cutting themselves off from friends and neighbors, reluctant to face the world. Some of these families, often called shidu families, even face discrimination or stigmatization, as losing a child is sometimes thought to be a sign of bad luck in China. Song’s research found that there were nearly 2.5 million families in China who had lost their only children, compounding their everyday challenges. These families often quit their jobs or retire early after the death of a child, increasing financial hardship and keeping many from receiving pensions. Over half of these elders are depressed and more than 60% of them have a chronic illness of some kind, a statistic that Nie’s research also uncovered.

What long-term care options exist?

Long-term eldercare in China, as discussed above, has traditionally been provided almost exclusively by adult children under the ideals of filial piety. Lu, Liu, and Piggott (2015) categorize long-term care provision two ways, formal and informal care. Formal long-term care options, they say, includes options such as nursing homes and community sponsored programs and support. These options, however, are typically limited to the urban areas of China, along with the more economically developed eastern part of China. The vast majority of elderly Chinese in central and western China only have access to informal care provided by their grown children. Lu et al. defined informal long-term care as unpaid care given by family members or friends in support of daily living activities. This support, they said, can range from occasional help with tasks like shopping to continual support with eating, bathing, and general mobility. Their research highlighted that informal care drastically reduces the probability and severity of hospital care, and must be regarded as the single most important resource for the aging population (Lu et al., 2015). However, it seems that informal care is no longer a viable option for many of China's elders.

How could China change or reform its long-term eldercare policies?

China’s eldercare policy development and implementation have been too little, too late, and experts say that the policies are desperately in need of reform. Lu, Liu, and Piggott (2015) determined that long-term care policies barely exist in China, and where they do exist, they are poorly funded. Furthermore, their research concluded that the existing policies tend to only target families with one child or whose child has died, operating on a misguided assumption that informal care is scarce due to the effects of the one-child policy. They emphasize that a fully funded long-term care policy would be costly for the country and that current policies are not taking into account informal care as an integral part of long-term care provision. Lu et al. warn that any long-term care policy developed without incorporating informal care would be a major, if not unsustainable fiscal burden for China (2015).

Conclusion

China is under huge societal pressure to provide adequate care and support for its elderly population in today's modern society. As the country continues to disentangle itself from the clutches to ancient tradition and charges forwards into its future, the elderly population is being neglected and abandoned with each passing year. It is clear that nothing short of complete reform of China's eldercare policies and support systems will ensure a safe and happy existence for the millions of grandparents who built the foundation of the country. Even the government's belated relaxation of the one-child policy a few years ago comes too late to help those in need right now. It remains to be seen what steps the government will take in the face of this enormous pressure, but hopefully, they will take quick and sustainable measures in order to rescue their aging society.

References

Chen, R., Xu, P., Li, F., Song, P. (2018). Internal migration and regional differences of population aging: An empirical study of 287 cities in China. BioScience Trends, 12(2), 132-141. doi: 10.5582/bst.2017.01246

Glass, A. P., Gao, Y., Luo, J. (2013). China: Facing a long-term care challenge on an unprecedented scale. Global Public Health, 8(6), 725-738. doi: 10.1080/17441692.2013.782060

Gui, T., Koropeckyj-Cox, T. (2016). “I am the only child of my parents:” Perspectives on future elder care of parents among Chinese only-children living overseas. Journal of Cross-Cultural Gerontology, 31(3), 255-275. doi: 10.1007/s10823-016-9295-z

Gustafson, K., Huang, B. (2014). Elderly care and the one-child policy: Concerns, expectations, and preparations for elderly life in a rural Chinese township. Journal of Cross Cultural Gerontology, 29, 25-36. doi: 10.1007/s10823-013-9218-1

Hou, J. W., Li, K. (2011). The aging of the Chinese population and the cost of health care. The Social Science Journal, 48, 514-526. doi: 10.1016/j.soscij.2011.06.002

Lu, B., Liu, X., Piggott, J. (2015). Informal long-term care in China and population aging: Evidence and policy implications. Population Review, 54(2), 28-41. Retrieved from: https://muse-jhu-edu.ezproxy.umuc.edu/article/591657

Nie, J. (2016). Erosion of eldercare in China: A socio-ethical inquiry in aging, elderly suicide and the government's responsibilities in the context of the one-child policy. Aging International, 41(4), 350-365. doi: 10.1007/s12126-016-9261-7

Pei, X., Luo, H., Lin, Z., Keating, N., Fast, J. (2017). The impact of eldercare on adult children’s health and employment in transitional China. Journal of Cross Cultural Gerontology, 32, 357-372. doi: 10.1007/s10823-017-9330-8

Qu, B., Li, X., Liu, J., Mao, J. (2012). Analysis of the current situation regarding the aging rural population in China and proposed countermeasures. Population Health Management, 15(3), 181-185. doi: 10.1089/pop.2011.0033

Song, Y. (2014). Losing an only child: The one-child policy and elderly care in China. Reproductive Health Matters, 22(43), 113-124. doi: 10.1016/S0968-8080(14)43755-8