Smart Solutions for Improving the Elderly Care System in Hebei

One of the demographic challenges faced by the People's Republic of China is an aging population, which has significant economic impacts. Photo credit: ADB.

Online training of caregivers using a popular mobile app and a digital monitoring and assessment platform help improve the quality of services.

Overview

The People’s Republic of China (PRC) is aging at an unprecedented rate. Among the challenges the country faces are increasing demand and costs for quality care for seniors or those aged 60 or older.

Hebei is one of the PRC provinces that has reached “aging society” status. It crossed the threshold in 1999 when those more than 60 years old comprised 10% of the population. The senior population was projected to have reached 17% in 2016 and is expected to rise to 31% by 2050—just below the national estimate of 34%. The province was not ready to support its aging population. There were severe shortages of residential care facilities, community elder care services, and skilled caregivers.

knowledge and technical assistance grant to support a project funded by the Asian Development Bank expanded access to elder care services and improved the capacity of caregivers in Hebei through knowledge and skills training using an online communications application (app). It also developed an efficient monitoring and assessment platform and promoted the involvement of civil society organizations.

Project information

TA 9326-PRC : Establishment of an Integrated Comprehensive Three-tier System for Elderly Care

Project snapshot

      • Approval date: 6 June 2017
      • Closing date: 27 January 2022
      • Total project cost: $44.37 million
      • Executing agency: Hebei Provincial Government
      • Implementing agency: Project Management Office of the Hebei Provincial Department
      • Financing: Asian Development Bank

Context

Fast urbanization, migration of youth from rural to urban areas, and the one-child policy weakened traditional family support systems, which provided care for older relatives in the country.

The PRC government’s Twelfth Five-Year Plan (2011–2015) supported the creation of a three-tiered elder care system with home care as base, community care as support, and institution-based care as supplement. In line with international trends, this system values “aging in place” (seniors live in their own home and community), de-institutionalization, and active aging.

The country’s Thirteenth Five-Year Plan (2016–2020) seeks to expand coverage and enhance the quality of elder care services by developing the capacity of the private sector and civil society organizations to play a greater role.

Challenge

In 2020, there were 14.81 million people over 60 years old in Hebei. However, there were only 1,721 residential elder care centers with 214,000 available beds, which could only serve 1.3% of the projected demand.

This situation was further aggravated by insufficient staffing and inadequate skills of caregivers at county, township, and village levels, as most of the licensed caregivers are concentrated in urban residential districts. Mainly family members or community caregivers took care of older people. In five counties, the average profile of caregivers was rural female, aged 35–60 years old, and less educated. There were also no standardized training programs for both institutional and family caregivers in these areas.

Solutions

As an aging society, Hebei has a strong desire to identify strategies, models, and partnerships that can deliver affordable and quality elder care services that address diverse needs.

The technical assistance component of the Hebei project sought to promote and expand the three-tiered health care system by delivering module-based trainings that cover a variety of topics through an online communications app for wider access by family, community, and institutional caregivers at county, township, and village levels. These trainings were designed to build their capacity to provide basic services to older people who require daily care from chronic and geriatric diseases, rehabilitation, and dementia-related support.

Leveraging the use of a popular app

WeChat, a popular messaging and social media application in the PRC, was used as a knowledge dissemination platform to livestream the training and demonstration videos. The content was provided by the leading elder care residential institutions in Beijing and delivered by experts in the field to help caregivers learn new skills and upgrade professional standards. Chat groups were created to facilitate questions to experts. Caregivers can also request interactive sessions with the trainers through this app. The use of this platform made capacity building more convenient and less costly than face-to-face training.

Upon completion of the technical assistance, Yanshan University took over this service model and expanded the training scope to include geriatrics, health maintenance, and functional rehabilitation.

Building a monitoring and assessment platform

An information and communications technology (ICT) platform was built to monitor and assess the quality of elder care in She and Shuangluan counties, which are located in the economically less-developed parts of Hebei. They were selected based on the demand of the local civil affairs bureau.

The evaluation criteria for elder care institutions are based on national standards and further segmented into detailed assessment categories, such as hygiene and sanitation, food safety, quality of medical and health care, and contract management. The appointed evaluators visit each residential care center in the counties, complete the evaluation results online, and then upload the evaluation results through the platform. Once submitted, the evaluators cannot change the submitted data. The assessments guide the elder care institutions and the civil affairs bureau in identifying bottlenecks and required improvements.

Results

  • The project planted the seeds to enable innovative solutions and practices for delivering and scaling up quality elder care services.
  • The WeChat livestreams reached more than 250,000 viewers, which would have been difficult to achieve in a face-to-face setup given the limitations brought by the coronavirus disease (COVID-19) pandemic.
  • Data from the monitoring and assessment platform led to more accurate gap analysis and improved the operational efficiency, safety, and quality of services and contract management for the residential elder care centers in She and Shuangluan counties.
  • The project provided roadmaps and recommendations for the voluntary sector as a resource to expand the scope and provision of elder care services.

Lessons

  • Innovative technologies, such as mobile communications apps, play a crucial role in building smart communities. They can be leveraged as a knowledge-sharing tool to help train and educate people from different locations at the same time. ICT platforms can also be utilized for efficient data analysis and management to help authorities make evidence-based interventions.
  • It is important to differentiate the needs and challenges of the target populations to achieve maximum impact. For instance, in a less developed area, the focus should be on urgent basic needs, such as providing the minimum number of beds required in a village or county and establishing the fundamentals for developing a “silver economy” for its aging population. In more advanced areas, the needs of the aging urban population will require a different approach and project design.
References
Author
Lanlan Lu

Lanlan Lu

Senior Project Officer, East Asia Department, ADB

This blog is reproduced from Development Asia.

Approaches to Eradicate Absolute Poverty in Guangdong Province, the PRC

Eradicating Absolute Poverty in Hunan Province, the PRC

COVID-19’s Initial Impact on Food Supply Chains, Rural Migrants, and Poverty in the PRC

Development and Performance of the Elderly Care System in the PRC

Cities for the Young and Old

Rethinking urban design necessary to ensure sustainable, healthy and age-friendly urban communities.

The last 40 years have seen soaring urbanization in the PRC, as a result of which 60 percent of its population now lives in urban areas. the PRC’s society is also aging rapidly. As these two trends are ongoing, the PRC needs to make its cities more livable, healthy and age-friendly, as well as environmentally sustainable and socially inclusive.

Contemporary urban life in the PRC and elsewhere has seen increased individuality with reduced social cohesion, smaller families, fewer children and many people living alone. This requires reconsideration and improvement of the social security and pension systems and health and elderly care services. But city design and urban management also have roles to play in addressing these issues by promoting social cohesion and restoring community life.

For example, the PRC could promote healthier and more age-friendly cities with cohesive neighborhoods if it rethinks and rehabilitates its system of compounds. The rehabilitation of urban compounds in the PRC will need to be a comprehensive and participatory effort to promote improved health, safety, resilience and an active community life.

This means reducing the number of fences and gates and introducing new pathways for pedestrians and bicycles through compounds to create a finer mesh of pedestrian and bicycle networks. In the process, walking distances would be significantly shortened. Also, new small buildings with two to four stories can be introduced, as careful in-fill development between residential high-rise buildings, with community spaces, small shops and other uses.

All these will create a more humane environment amid the typical wide roads and tall buildings, as well as create well-defined spaces that are either public or semi-public for local residents, or private for individual households.

If Chinese cities and urban spaces can be made less dependent on cars, this would bring healthier lifestyles to the residents and enable more interaction within communities. That would be good news for everybody, especially the elderly and children.

One out of every five people will be aged over 60 in the PRC by 2030, heralding a “super-aged society”; and it will rise to more than one in three by 2050. Many of these elderly will age further, becoming part of an emerging four-generation urban society. It is a trend observed not only in the PRC but in many other countries, especially high-income ones. The pressures of an aging society and inaccessible urban environments affect women disproportionally due to their longer life expectancy and care duties.

Recognizing this, urban planners could consider a number of internationally recognized best practices for sustainable urban development. These include the “compact city” concept, in which an urban area is organized in clusters of pedestrian-friendly, high-density mixed-use centers within walking distance of public transport stations, inclusive of green open space. This is known as transit-oriented development.

Other practices are low-carbon development, to which compact cities contribute, and climate-resilient urban development. In this, green infrastructure and parks are combined with gray infrastructure to provide flood and drought risk management, air quality and microclimate improvements, habitat for a diversity of plant and animal species, and green amenities for urban residents.

The overall objective must be to make cities liveable and socially inclusive. This includes not only environmentally sustainable planning but ensuring access to affordable and social housing and to public services, education, health and attractive jobs. Integrating health and aging into sustainable urban environment improvement and city planning and urban design will bring together many agencies and specialists to work across sectors and disciplines.

While these good principles create many benefits, it is important to adapt health-and age-specific features into cities and new urban developments, buildings, infrastructure and open spaces. This will be vital for urban competitiveness and will influence individuals’ and companies’ decisions to remain in a certain city or relocate to another.

Making cities healthier and more friendly to the elderly and children requires well-planned urban green spaces, safe, clean and walkable urban environments, and accessible services and facilities for these groups. Women who tend to live longer than men will in particular benefit from these improvements. All of these will help ease public health management in an era when infectious diseases such as the COVID-19 pandemic, noncommunicable diseases and the challenges of aging populations are converging.

Cities also need to combine an age-friendly public transport system with safe and convenient sidewalks and pathways, bicycle parking, parks, public spaces and public service facilities. This effort needs to be integrated with universal urban design to ensure that public spaces, sidewalks, parks, and buildings are accessible for people of all ages and the physically impaired.

Prioritizing health and age-inclusion will not only become the driver and platform for action to address the many challenges of the emerging four-generation cities, but is also a great opportunity to transform urban community life for the better.

Neighborhoods, if designed well, would encourage all residents to contribute to the care of children and the elderly, just by being part of a highly interactive local community.

Urban rehabilitation and retrofitting would reduce carbon emissions as people walk more, and contribute to the country’s objective of peaking carbon emissions before 2030 and reaching carbon neutrality before 2060.

If these principles of urban rehabilitation are applied, local social cohesion and wellbeing in the PRC’s cities will also improve. Urban health and age-inclusive designs will also contribute to the Healthy the PRC 2030 Plan and more generally promote well-being and high-quality development, an overarching objective of the 14th Five-Year Plan (2021-25).

Authors
 Stefan Rau

Stefan Rau

Senior Urban Development Specialist, East Asia Regional Department, ADB

This Op-Ed is reproduced from China Daily.

Meeting Challenges of an Aging Society

The population in the PRC is aging rapidly. The proportion of people aged 60 or above is expected to increase to 35 percent by 2050, turning the population into one of the oldest in the world. While aging poses great challenges, if managed well, these can be overcome to create opportunities.

Reforms for fostering labor mobility and upgrading human capital will reduce the labor shortages stemming from an aging population. Greater public and private investments to strengthen elderly care services and facilities will create employment opportunities and improve people’s well-being.

Benefits of greater labor mobility

Mobility restrictions in the PRC-the household registration system (hukou) and inability of migrants to claim social security benefits away from home-discourage transfers from provinces where there is a surplus of labor to ones where there is a deficit. Re-allocating labor from low- to high-productivity sectors could add several percentage points to GDP growth. And accelerating the ongoing relaxation of the hukou policy and social security reforms for migrant workers to gain access to social services and benefits in their place of residency will remove such institutional mobility barriers.

The benefits of greater mobility can be maximized through increased investments in human capital. Gross enrollment rate in the PRC’s senior high schools and the percentage of population with tertiary education in scientific and technical subjects need to increase. The growing digitalization of the economy adds pressure to the task.

While new learning methods should encourage lifelong learning, creativity, innovation, and problem-solving skills, incentives must be introduced for companies to provide on-the-job training, and initiatives to re-train workers whose skills are obsolete to prolong their participation in the labor force.

Increasing female participation in the labor market will also help maintain the labor supply. Although gender gaps in education have largely closed, female workforce participation has declined over the past decade, and women continue to bear a disproportionate responsibility for unpaid care work at home and remain under-represented in scientific research and high-technology industries and services. Policies for equal employment opportunities, increased maternity leave, improved support for childcare, elderly care, and single mothers, are essential to attract and maintain women in the labor force.

Better services and care for the elderly

Under the PRC’s 14th Five-Year Plan (2021-25), development of an efficient long-term care (LTC) system is a government priority. Insufficient elderly care facilities result in unnecessary admissions in acute care hospitals and are a waste of healthcare resources. Improved home- and community-based LTC can address this issue. Incentives to develop home- and community-based services, such as home help, home care, and home nursing services, and center-based services to support the elderly are critical to meet the”90-7-3 older persons care pattern “launched during the 12th Five-Year Plan (2011-15) period in which 90 percent of the elderly population should receive home-based care, 7 percent community-based care, and 3 percent institutional care.

More affordable elderly residential care for lower-income households that need assistance is part of the solution. These facilities can be funded by a mix of government support, individual pension contributions, and private sector involvement. This approach is emerging in the PRC but needs to be strengthened. These efforts will benefit from a shift in the role of the government from supplier to regulator for the provision of LTC. Examples of government tasks include setting policies and standards, subsidizing people who cannot afford the private facilities, and incentivizing private sector participation, which can engage in effective models of public-private partnerships.

Incentives and policies need to be improved

At the same time, incentives and policies to retain and train LTC givers must improve. Professions crucial to a well-functioning elderly care system, including nurses, physiotherapists, occupational therapists, nutritionists, medical specialists (that is, neurologists, specialists in geriatrics), social workers, service providers, and managers must expand. The number of professionals in paramedical, medical, social work and elderly care management should also increase, as those will result in better care and improved services for the elderly, as well as significant employment opportunities.

Addressing the needs of an aging society is costly. Public healthcare expenditure in the PRC stands at 2.9 percent of GDP compared with the 6.5 percent average in the Organisation for Economic Co-operation and Development countries, where LTC alone amounts to 1.7 percent of GDP. the PRC has made significant progress in extending health insurance coverage universally, but out-of-pocket payments still account for about half of the total health expenditure, exacerbating the vulnerability of lower-income households. Expanding health insurance coverage, reducing co-insurance rates, and introducing ceilings on maximum out-of-pocket payments are reforms that have proven effective in other countries.

Increased funding should not threaten fiscal sustainability. A more progressive taxation system, the further liberalization of energy and resource prices, and the introduction of environmental and property taxes would increase social spending without straining public finances. Policy reforms, too, can help. Affordable social services, higher pensions, and support to women through subsidies for childcare, baby bonuses, child grants, flexible hours, or part-time work, are key to lift fertility rates mitigating the impacts of an aging society.

While gradual increases in retirement age will strengthen labor supply and support the sustainability of the pension system, which is crucial for the success of a multigenerational workforce, age-friendly policies, such as more flexible work options, retraining, re-skilling, and age-friendly workplaces are important during the transition. Finally, the sustainability of the pension system is critical in an aging society. For that, the introduction of voluntary private pension funds, currently piloted in Zhejiang and Chongqing, needs to progress faster.

Authors
Yolanda Fernandez Lommen

Yolanda Fernandez Lommen

Country Director, PRC Resident Mission, ADB

This Op-Ed is reproduced from China Daily.

Easing the Burden of Disease on the Poor through Financial Protection

An expanded public health service package provides basic health services to the entire population. Photo credit: ADB.

In the People’s Republic of China, reducing the risk of illness-induced poverty entails raising the poor’s financial protection and health system reforms.

Introduction

By achieving near-universal population coverage of social insurance, the People’s Republic of China (PRC) has improved access to and use of health services and reduced the proportion of out-of-pocket (catastrophic) spending. Yet among the country’s poor people, catastrophic health expenses are still high despite the government’s attempt to provide additional financial protection.

The current insurance system should target underprivileged populations to enhance financial protection in the country. Such targeting requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency. To break the vicious cycle of illness-induced poverty and return to poverty because of illness, the protection of poor people from health care costs should be regarded as an important element of poverty alleviation in the PRC. Increased spending on health, however, will not improve financial protection without further measures to increase health system efficiency, strengthen primary care, and reform provider payment systems.

Context

The United Nations Sustainable Development Goals in 2016 committed countries to achieve universal health coverage by 2030 with a focus on essential health services and financial protection. Universal health coverage means that all individuals and communities should get the quality health services they need without incurring financial hardship. It has three dimensions: population coverage, covering all individuals and communities; service coverage, reflecting the comprehensiveness of the services that are covered; and cost coverage, the extent of protection against the direct costs of care.

In 2009, the PRC began implementing comprehensive health system reforms. A major goal of these reforms was to achieve universal health coverage by building a social health insurance system. According to a 2017 monitoring report by the World Health Organization and the World Bank, the PRC had a fairly high score for coverage of essential health services on 16 health indicators but a low score for financial protection to reduce the risk of illness-induced poverty.

This policy brief examines the PRC’s progress in enhancing the financial protection of social health insurance and identifies the main gaps yet to be filled to fully achieve universal health coverage. It is based on a paper by Hai Fang, Karen Eggleston, Kara Hanson, and Ming Wu, published in volume 19 of the journal BMJ.

Policy Solutions

The 2009 health system reforms proposed a universal health insurance system that consisted of three main social health schemes in each locality: Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and Rural New Cooperative Medical Scheme, with other supplementary insurance and private insurance. The reforms aimed to cover the entire population with one of the three basic schemes to give them greater financial protection. In 2016 with some heterogeneity by locality, the urban resident and rural schemes merged to form the Urban—Rural Resident Basic Medical Insurance to improve administrative efficiency.

To give added protection to patients with critical illnesses, catastrophic medical insurance (also called critical illness insurance or Da Bing Yi Bao) was initially launched in 2012 and implemented nationally in 2015. It covers patients with critical illnesses whose out-of-pocket expenses are more than the average disposable income per capita in the local area, providing extra reimbursement and removing the benefit ceiling.

The medical aid program (also called medical financial assistance or Yi Liao Jiu Zhu), which was launched in 2003 in rural areas and expanded to urban areas in 2005, provides a further safety net. It was designed to provide medical aid to the poorest people by paying their medical insurance premiums and reducing out-of-pocket expenses after receiving reimbursement from the basic social health insurance schemes and catastrophic medical insurance.

Policy Implementation

The national health reforms of 2009 consolidated a fragmented health insurance system, creating an expanded public health service package that provides basic population health services to all Chinese. Recent mergers of insurance risk pools—such as raising benefit levels of the New Cooperative Medical Scheme to those of the Urban Resident Basic Medical Insurance—and implementation of catastrophic supplementary insurance within local social health insurance systems are encouraging trends for closing gaps in risk protection.

Over the past 2 decades, health spending has grown considerably as the economy experienced unprecedentedly rapid growth. By 2017, the government share of spending represented slightly over 9% of overall government expenditures. The money to invest in the expansion of healthcare came from a mix of central and provincial budgets, with per capita budget allocations that include higher central government subsidies for lower-income provinces. Funding for the medical aid program comes mainly from governments, welfare lotteries, and social donations. Meanwhile, a governance reshuffle consolidated the purchaser role for social health insurance schemes under the newly created National Medical Security Administration, with most other functions assigned to a rechristened National Health Commission.

The PRC also invested a substantial amount of public funds in health services. Government health care budgets financed construction and renovation of government primary care facilities, subsidies to replace provider revenues generated from drug dispensing, purchase of medical equipment for public hospitals, expansion of public health services, and training and continuing medical education.

The increased health spending—directly on healthcare infrastructure and subsidizing social health insurance for the rural and urban non-employee populations—substantially reduces the burden on families. Furthermore, the PRC’s world-leading technological prowess in multiple fields spanning digital commerce to artificial intelligence—and accompanying innovative business models for online consultations that have not yet been fully integrated into the health system—hold promise for supporting higher quality and more convenient health care for the country’s 1.4 billion citizens.

Policy Outcomes

Reforms over the past 2 decades have brought the health care system closer to a level of reliability and accessibility commensurate with the country’s new affluence. The consolidation of the social health insurance system ensured coverage of the entire population for basic health services, contributing to a surge in health care utilization while reducing out-of-pocket costs to patients.

The percentage of people who reported a need for hospital admission but did not receive inpatient care decreased from 29.6% in 2003 to 25.1% in 2008 and 17.1% in 2013. The average number of outpatient visits per capita increased from 1.7 in 2003 to 5.9 in 2017, and the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017. The use of outpatient services was comparable with the global average, but admission rates were much higher. Furthermore, the government’s investments into the public health system substantially increased the number of health workers and hospital beds and helped keep the prices of health care services low.

The expansion of health insurance coverage reduced the share of out-of-pocket health expenses in total health expenditures from 56% in 2003 to 29% in 2017. It is projected to decrease to 25% by 2030.

Catastrophic medical insurance and medical aid were effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups, including people who are poor, chronically ill or disabled, disadvantaged by geographical factors, very young, or frail and old. By 2017, catastrophic medical insurance covered more than a billion people in the PRC and 11 million people received extra benefits of more than ¥30 billion (about $4.3 billion).

The insurance reduced the average proportion of out-of-pocket expenses after reimbursement from basic social health schemes by about 10%. In 2017, through medical aid, 56.2 million people (4% of the population) received subsidies to pay for their social health insurance premiums. For the same year, 35.2 million people (2.5%) received on average ¥757 (around $118.84) or about 12% of average inpatient spending per admission to cover out-of-pocket expenses.

References

Center for Health Statistics and Information, National Health and Family Planning Commission. 2015. An Analysis Report of National Health Services Survey in China, 2013. China Union Medical University Press.

Central Committee of the Communist Party of China and the State Council. 2009. Opinions on Deepening Health System Reform.

Chinese Ministry of Finance and Ministry of Civil Affairs. 2013. Announcement about Management Methods of Urban Rural Medical Aid Funding. 23 December.

H. Fang et. al. 2019. Enhancing Financial Protection under China’s Social Health Insurance to Achieve Universal Health Coverage. BMJ. 365: l2378.

H. Li and J. Jiang. 2017. Catastrophic Medical Insurance in China. Lancet. 390: 1724–5.

Author
 Karen Eggleston

Karen Eggleston

Deputy Director, Shorenstein Asia-Pacific Research Center, Stanford University

This blog is reproduced from Development Asia.

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