Ageing in China: health and social consequences and responses

J Wooa, T Kwoka, FKH Szea and HJ Yuanb

a Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
b Centre for Geriatric Medicine, Health Maintenance and Training, West China Medical University, China.

Prof. Jean Woo, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong. E-mail: jeanwoowong{at}cuhk.edu.hk

The People’s Republic of China consists of 32 provinces and a special administrative region (Hong Kong) and is home to 1.27 billion or roughly one-fifth of the world’s population. Although the majority ethnic group (94%) is Han, there are altogether 56 ethnic groups with differences in language, religion, and lifestyle. There is huge income inequality, from multi-millionaires in urban regions to those in rural areas who have difficulty getting enough money for daily necessities. As a result there is a wide variation in lifestyle, morbidity and mortality patterns. A government survey in 1999 showed that the number of people aged over 60 has reached 127 million, or 10.1% of the total population.1 With population ageing, the increasing degenerative disease burden and social implications have placed elderly issues on the agenda of all government sectors. This article describes the demography, living arrangements, morbidity and mortality of the ageing population, and the present health and welfare systems. How the government responds to the health and social consequences of ageing, and the future outlook will be discussed.

Demography and living arrangements

The population in China as a whole is ageing, the percentage of people aged 65 years and over rising from 5.5% in 1990 to a predicted 13.3% in 2025,2 and 23%, or 114 million, by 2050. The life expectancy at birth for China is 68 years for men and 73 years for women, while corresponding figures for the Hong Kong special administrative region (SAR) are 76 years for men and 83 years for women. The proportion of people aged 65 years and over living in major cities shows rapid changes. For example in Beijing, this figure was 14% in 1999, but projected to double to 30% by 2025.3 Similarly, the corresponding figures for Hong Kong are 12% and 26.8%. The proportion of the elderly population is a little higher in the rural areas, and the poorest western parts of China will be the fastest ageing area. The difference in average annual income compared with urban areas may be two to fivefold (1122–2720 RMB versus 3299 to 5216 RMB: 1 US$ = 8 RMB). With the change to a market economy emphasizing reliance on individual effort and the birth control policy of one child per family, the extended family structure of 4:2:1 has become the norm (two sets of grandparents, two parents and one child). There is an emphasis on personal success and happiness, which may conflict with the responsibility of living and caring for elderly members of the family. There are concerns that respect for the latter is diminishing and they are increasingly being regarded as consumers of resource within the family and in society as a whole.4 The attitude to the ageing population may be summed up by the need to ’... face the coming of the turbulent waves of the white haired ...‘4

Mortality, morbidity, and disability

With economic development, the prevalence and mortality rate of non-communicable diseases is likely to become a long-term economic burden. Between 1930 and 1980, the rate of increase in the contribution of stroke, cancer and heart disease to mortality in China was steeper than in the US. By 2030, the annual deaths from coronary heart disease, stroke and lung cancer are estimated to reach 800 000, 3 million, and 1.7 million, respectively.5 In metropolitan cities like Beijing, Shanghai, and Hong Kong the top three causes of mortality are cancer, coronary heart disease and stroke. There is a lack of comprehensive data on prevalence of chronic disease in China, and available data only refer to urban areas. It is likely that there are marked differences in the prevalence of non-communicable diseases between urban and rural areas, reflecting socioeconomic and lifestyle differences. For example, the suicide rate per 100 000 population in 1994 among those aged 65–74 years in rural areas was 101.5 and 74.7 for men and women, respectively, compared with 16.9 and 15.6 in urban areas. In comparison the UK figures were 10.7 and 4.3. However, there are large scale random samples collected from the regular Health and Nutrition surveys conducted by the government. The 1990 survey covered the urban areas of seven provinces and consisted of 34 355 people, with approximately equal numbers of men and women. It was noted that the prevalence of non-communicable diseases was rising compared with the survey findings in 1986, particularly for hypertension, coronary heart disease, stroke, and chronic bronchitis. There were marked differences between provinces, in that the highest prevalence for hypertension and coronary heart disease was found in Beijing (10% and 8%, respectively), while the more underdeveloped provinces such as Ning Xia had lower prevalences of these diseases. No comparable figures are available from the Hong Kong SAR, although data are available for the elderly population, again showing the predominance of hypertension, ischaemic heart disease, stroke, diabetes, osteoporotic fractures and dementia.6 In a cohort study of people aged 70 and above, the annual incidence per 100 000 population was estimated to be 1300 for cancer, 950 for stroke, 888 for heart disease, and 540 for chronic obstructive pulmonary disease (Woo et al., unpublished data). Non-communicable diseases constitute the major cause of disability, accounting for approximately 60%, the other causes being communicable diseases, maternal, perinatal and nutritional conditions, and injuries.7 About 35% of remaining lifespan at 60 years is expected to be lost due to disablility.7 The figure for the Hong Kong SAR is lower, being 26% (men) and 35% (women) at 70 years (Woo et al., unpublished results). Diseases making the largest contribution to disability are stroke, dementia, fractures, Parkinson’s disease, and diabetes mellitus.8

It is important to note that communicable diseases continue to have a major impact on population health. It is estimated that there are 5 million cases of tuberculosis in China, with similar rates in both China and Hong Kong SAR.7,9 The other communicable diseases of note are: hepatitis B (estimated 120 million carriers), HIV/AIDS (estimated 400 to 600 000 carriers) and other sexually-transmitted diseases, the latter showing a 30% increase in recent years.

Healthcare and social welfare systems

The health service in China is transforming from a solely government financed system to a government subsidized one, following the change to a market economy in recent years. In contrast to the primary care system present in many western countries, primary care is mainly carried out at ‘Street Block’ clinics serving the people living within a few blocks of streets in urban areas, at factory clinics serving the workers employed, and at clinics staffed by the less intensively trained medical personnel—‘Bare-Foot Doctors’—in rural areas. Approximately one-third of rural outpatient care and one-quarter of inpatient care is provided by traditional Chinese medical practitioners. The rural co-operative medical system (CMS), formerly funded by premiums, a collective welfare fund and government subsidies, has changed to a system where over 90% is paid out of pocket by patients. In the cities, almost all employees used to have medical coverage provided by the government, since there was little private enterprise before the economic reforms. Dependants of these employees could enjoy a subsidy of about 50% of the medical costs of care. Currently medical care in urban areas is undergoing reforms. The trend is for the government employees to pay for a certain percentage of their medical costs before they can enjoy the government subsidy. As a result, people go to the local pharmacy, and based on the recommendations of the staff there, purchase medicines for common problems like coughs and colds. If the problem becomes more severe, they will go to the Street Block Clinic or hospital. At present, costs are relatively high—the average monthly income is only RMB 1000, while outpatient treatment for a common cold in Beijing is RMB 150, inpatient room charges are RMB 50 daily and cataract removal costs RMB 6000. If annual costs are over RMB 2000, only 10% of the excess is paid by the patient with the government picking up the balance. Homes for elderly people are few and costs are extremely variable, but generally care at home is cheaper (about RMB 400 a month), is readily available, and may be more socially acceptable.

There is an increasing trend towards buying health insurance from China-owned companies. However, the terms may not be very favourable. American International Assurance is the only foreign company allowed to practice in China. Other foreign companies operate in Hong Kong, attracting customers to buy insurance there as part of package tours from China to Hong Kong. For workers, there is a social health insurance programme to which employers contribute 6% and employees 2% of wages. The Chinese government has been estimated to spend 100 million RMB in retirement pay currently. The proportion contributed by employees has increased from 13.7% in 1978 to 35% in 1993.10 A monthly old age allowance is only available to government cadres at 65 years, and for employees of organizations like universities at 75 years, if they have worked for at least 30 years, the amount depending on the years of service. In urban areas, about 50% of the population may be receiving old age allowance, while no one in the rural areas is receiving this subsidy.

In contrast, Hong Kong SAR has a comprehensive range of medical and social services, based on the UK model.6 All are entitled to a non means tested old age allowance at age 65 years, and there is a range of allowances for disability, disease, unemployment, and a subsidy for long term residential care. The government has just started a mandatory provident fund so that all workers will receive a pension on retirement. Social Welfare Services provide meals-on-wheels, home helps, and manage the administration of long term residential care homes. Primary care is provided by private practitioners (85%) and government clinics (15%) at low cost. Accident and emergency attendance is free, and specialist outpatients and inpatient fees are low (HKD 44–65; 1 GBP = 11.2 HKD) and may be waived. Inpatient care is inclusive of all investigations and treatment, as well as meals. There are geriatric Day Hospitals and community geriatric and psychogeriatric outreach teams to support residential care homes. The public may also opt to receive care in the private sector. Therefore a good quality health care system is accessible to all, and not dependent on individual affordability.

Health and social policy

Much emphasis has been placed on prevention of chronic diseases. China has an excellent infrastructure for carrying out surveys to monitor health and nutritional status, and to disseminate public health messages, through its system from central government to provinces and autonomous regions, municipalities, cities, and streets. Each of these units is supervised by a designated person. Thus the Ministries of Health, Agriculture, Public Security and National Statistics Bureau aided by the FAO and WHO, together with the Institute of Nutrition and Food Hygiene of the Chinese Academy of Preventive Medicine, have conducted national health and nutrition surveys in 1959, 1982, 1990, 1992. The Ministry of Health also established a working group for elderly health care in 1995, as well as a national Geriatric Institute to conduct research in the areas of epidemiology, biochemistry, immunology, genetics and cellular biology. Currently there are about 50 organizations for geriatric care and 2000 health care workers nationwide.1 Various community-based service models have started in cities as well as rural regions. The central role of the family in caring for the elderly is being reinforced as part of ‘moral’ education in carrying on Chinese traditions.5 The general public is being introduced to the problem of elderly people, and these issues are being drawn to the attention of leading government cadres at all levels. Certain provinces (e.g. Shandong) have developed written agreements between parents and children regarding provison of family care, specifying daughters-in-law in addition to immediate family members as potential future carers.

In 1996, the standing committee of the National People’s Congress promulgated the Old Age Law in China.3 The law emphasizes the role of the family in offering support to the elderly. It reinforces the function of the social security system, particularly in rural regions where it will be more important than in urban regions. It highlights the five basic needs of the elderly as a target to be achieved: the need to have a carer, to have health care, to have opportunities to study and learn, to have opportunities to continue to contribute to society, and to live a happy life. The law advocates active ageing and participation, and calls for increasing government input. The latter is mainly in the form of moral support and encouragement, together with investments in housing, elderly care centres, and education. An example of how these principles have been put into practice is the formation of the Beijing Retired Personnel Development Center3 in 1986. It provides education and psychological consultation for elderly people. At the same time it functions as an employment agency, matching the previous occupation and expertise of over 80 000 elderly people to demands for such expertise by various enterprises. Further examples are Senior Citizen Universities which form a good venue for promoting healthy ageing,11 and the Centre for Geriatric Medicine, Health Maintenance and Training of the West China Medical University which trains doctors and nurses in Geriatric Medicine, carries out health promotion, and creates service delivery models.12 In Shanghai, centenarians receive a certificate, a longevity star, 100 RMB/month for nutritional subsidy from the government, and the municipal or district hospitals pay home visits and carry out periodic physical examinations free of charge.13 In addition, the Shanghai Milk Company provides a daily bottle of free milk.

In parallel, the government of the Hong Kong SAR also recognizes the health and social consequences of population ageing. The government aims ‘to take care of the various needs of our senior citizens and provide them with a sense of security, a sense of belonging and a sense of worthiness‘;14 sentiments similar to the five basic needs of the elderly incorporated in the Old Age Law in China. A government Elderly Commission was set up in 1997 to oversee the development of elderly services, and an ad hoc committee on Healthy Ageing started working in 2000 to begin a 3-year campaign to promote healthy ageing in Hong Kong. Unlike mainland China, no large scale population health surveys have been conducted, and there is a lack of organized group health promotion efforts. In contrast, the development of geriatric, psychogeriatric, social welfare and long term residential care services have been developing at the same pace as Western countries.

Problems and future directions

The health and social consequences of an ageing population are well recognized by the government. As in other countries, theoretically much can be achieved by efforts targetted at disease prevention and maintenance of function by lifestyle modification, promoting a positive image of ageing, and re-engineering service delivery methods. However, politics and finance are major factors influencing the well-being of ageing populations, and the latter is seldom the major driving force behind the shaping of political platforms and financial strategies. In China, the government can only place its emphasis on preventive efforts.

Future plans include the development of undergraduate geriatric medicine training, establishment of geriatric units, and further research into health and medical care. The strategy is to develop comprehensive service systems covering medical, preventive, convalescent, physical, psychological and environmental aspects. Various modes of care, particularly community health care networks, outreach services, palliative care, in addition to geriatric clinics, health care centres, and day hospitals are being discussed. Healthy lifestyles are to be promoted to prevent chronic diseases and functional impairment. There is also an emphasis on equity of service provision. However, the financing of services is a major problem, since the current services are essentially private and income driven. The government aims to develop ‘low-cost programmes with optimum result‘, and ‘encourage individuals and families to invest in health‘—aims that are universal government aspirations. Social medical insurance and rural co-operative medical care will be developed.

What will be the likely impact of preventive efforts? In view of the magnitude of the problems of non-communicable diseases in an ageing population, shifting the population risk factor distributions downwards appears to be the most realistic option. Promotion of healthy lifestyles is therefore a major strategy which is probably more relevant to urban than poor rural areas. In the latter, the percentage of energy derived from fat is only half that in urban areas (12–18% versus 20–31%), with the main source of energy coming from cereals (73–83%, compared with 52–68% in urban areas).5 Increases in the consumption of higher-fat diets with increasing income have been documented.15 The dietary intake of Chinese communities in different geographical regions is affected by income and possibly by exposure to dietary health promotions, with the most adverse patterns occurring in communities where income is increasing but with little public health education about healthy lifestyles.16,17 The traditional Chinese diet has many favourable features with respect to prevention of cardiovascular disease and some cancers, in that the fat content is low and vegetable and fruit consumption is high.16 Undesirable features of the Chinese diet include its high salt intake, which predisposes to hypertension, and may explain the fourfold and twofold higher stroke mortality rates in China and Hong Kong, respectively compared with the US.17 The prevalence of hypertension between northern and southern parts of China differs by more than threefold, and stroke mortality by twofold, probably as a result of the high salt content of the Northern Chinese diet (about 15 g per day—recommended intake <=5–6 g), mainly from preserved vegetables.18

With urbanization, physical activity is reduced and the problem of obesity and the metabolic syndrome is increasing. For example, obesity clinics are being established in Shanghai. The level of physical activity in cities in China is likely to be higher than those in the US, for example, since bicycles are still an important mode of transport. For densely crowded cities such as Hong Kong, the design of the city is such that few people use stairs or walk any distance on steep roads.

Smoking has been estimated to cause 750 000 deaths a year in 1998 and the figure is predicted to rise to 3 million by the time the young smokers of today reach middle and old age.19 This has resulted in the government beginning to explore anti-smoking measures. It can be seen that health gains are possible in promoting healthy lifestyles, and the first step in the health education of the public should be achievable by the government. Perhaps the Chinese have an advantage, in that in Chinese culture there are codes of behaviour promulgated by various religious orders which consist of ‘ten commandments’ that summarize all the current recommendations for a healthy lifestyle in ten phrases.

Currently the total health care expenditure in China is 5% of GDP, but 80% of resources are concentrated in big cities that have only 15% of the country’s population. Recent health care reforms announced by the Minister of Health focus on managed care, as in the US, with the establishment of profit-making hospitals, emphasis on choice of doctors and hospitals as a measure to improve quality, contracting out of non-medical services, and fees for service. Such changes are encouraged by US academic collaborations with the Chinese Medical Association.20 With the shift to a market economy, the health services available to individuals will be largely determined by healthcare financing decisions and social welfare provisions. Currently the outlook is for a widening of the income gap in China which may negate the health gains from preventive efforts and development of health care systems targeted towards elderly people. In the Hong Kong SAR, where health care is essentially free or heavily subsidized by the government, and where there is also a marked income gap, the impact on health inequality is not so apparent.21 However, the current health care financing system cannot be sustained, as it is funded by taxation, which only one-sixth of the population pays. Therefore, both in China and the Hong Kong SAR, there is likely to be a shift towards a health insurance system and the emergence of for-profit health organizations and managed care. Judging from the experience in the US, the delivery of health care for elderly people under this system is problematic.

Conclusion

As in other countries all over the world, China faces an ageing population with increasing life expectancy and elderly support ratios. It is uncertain whether the future will be one of increasing disability as well. However, the health and social implications of this change are well recognized by the government, and action is being taken in the prevention of chronic diseases, and through setting up service delivery systems with an emphasis on community support and care. Training and research are also emphasized. The main concern is the method of health care financing, and whether developments can keep pace with the speed of population ageing. Given the lack of relationship between health care spending and life expectancy,22 and the fundamental social and economic causes of both communicable and non-communicable disease,23 it does seem that strategies focused on these primary determinants of disease are needed.

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