Who will care for you when you get old? A study of inequities in health and long-term care among the elderly in rural China

Lead Research Organisation: University of Kent
Department Name: Sch of Social Pol Sociology & Social Res

Abstract

The proposed study seeks to address key questions concerning the health and LTC among rural elderly in China, bridging the research gap in this area, and offering policy suggestions. People above the age of 60 account for more than 15% of the Chinese rural population. This percentage is expected to increase in the next few decades. In rural China, elderly people are relying on family members to provide care. However, as more and more young people are migrating to big cities, the expectation that family members will be available to provide care for rural elderly is becoming unrealistic. Institutional LTC care is usually expensive in China, and although the government partially reimburses the costs through a social health insurance scheme or other mechanisms, service users are still responsible for a substantial amount of co-payments. These costs may be too expensive for the rural elderly living in poverty to afford, which exacerbates the issue of unequal access to care.

The proposed study seeks to examine inequities in health and LTC among rural elderly in China. This study will first examine whether the socioeconomic status of the rural elderly is associated with their health status. It will then assess the impact of a non-communicable disease prevention and control programme on rural elderly with different socioeconomic backgrounds, and also examine whether the needs of the rural elderly population can be sufficiently addressed with home-based care support. The study will simulate the population structure of the rural Chinese in the next few decades, and predict whether the New Cooperative Medical Scheme (NCMS) (the only financial support available to the rural elderly to finance their LTC) will be sustainable in the long term. It will draw lessons on LTC financing from other developed countries, and propose potential policy recommendations for decision makers.

The study results will benefit a number of stakeholders including policy makers who are designing ageing-related policies in China, organisations specialising in home-based LTC services, the rural elderly and their family carers. The study results will reveal how the current health status and patterns of health care and LTC use among the rural elderly differ across different socioeconomic groups. The intention is to inform the policy making process and encourage policy makers to re-examine existing health and LTC policies. Organisations specialising in home-based LTC will also benefit from this study, because this study aims to identify whether the current family care is able to meet the needs of the elderly and identify areas where there may be opportunities to develop formal home-based LTC care. Finally, this study will benefit rural elderly and their family members by engaging them in various dissemination activities and dialogues with policy makers and other relevant parties.

This study will employ sophisticated econometrics methods, such as the Concentration Index, Instrumental Variables (IV), and various other simulation models. Data will be drawn from the China Health and Retirement Longitudinal Study (CHARLS). This study builds on initial quantitative skills in health inequity research I have developed from my previous work (e.g. the Concentration Index and Panel Data Regressions), and is complemented by training opportunities that the Future Research Leaders Scheme provides (e.g. advanced quantitative courses and various knowledge exchange workshops). The scheme will put me in a position to deliver strong evidence-based policy research that can influence policies.

Planned Impact

The proposed study is designed to address key questions concerning the health and LTC among the rural elderly in China, bridging the research gap in this area and offering policy suggestions. This proposed study will benefit a wide range of audience members. Potential beneficiaries and stakeholders are listed as follows:
1. Policy makers
National level: National Health and Family Planning Commission (NHFPC; formerly the Ministry of Health) of the People's Republic of China, Ministry of Civil Affairs (MoCA)
Provincial level: Provincial MoCA and Committee of Ageing (CoA), Zhejiang Province
This proposed study aims to reveal issues relating to inequities in health and LTC systems among the rural Chinese elderly, provide evidence of current and future need and demands of health and LTC services among rural elderly in China, as well as offer policy recommendations. At a national level, the study results may be used to raise awareness and inform policy makers in the NHFPC about health and LTC policies in rural China. In particular, RQ4 seeks to use a probabilistic population projection model and possibly other related simulation methods to conduct population level projections, and this will inform policy makers on the sustainability of the current Chinese health and LTC system, and offer recommendations regarding LTC policies for the rural elderly. Policy makers will be invited to become members of the advisory group, participate in the project workshop and conference, as well as comment on the research papers and the plain language report.

2. NGOs and other related social care organisations
RQ3 in this proposed study focuses on family care and other types of home-based LTC in rural areas. The findings may be useful for related adult social care service providers or organisations as evidence for developing activities relating to home-based elderly care in rural China.

The proposed research plans to make contact with home-based LTC providers through the researchers at Zhejiang University. Using the CHARLS survey Zhejiang sub-survey, the proposed research will present results on the level of unmet needs for the rural elderly who receive home-based care and identify relevant areas that social care providers or organisations should focus on. Representatives from social care providers will also be invited to attend workshops and exchange opinions and knowledge with government officials, academic researchers and service users, in order to inform their practice.

3. Rural elderly, family members of rural elderly in China
Issues relating to inequities in health status and the utilisation of health and LTC among the rural elderly should be examined and should be recognised. It is important to note that the burden of family care of the rural elderly should not only be shared with the elderly and their families, but also with the wider society. The proposed study calls for attention to be paid by the government, to take responsibility for provision of publicly-subsidised social care for the rural elderly. This will also reduce the burden for the rural family. The proposed research plans to invite rural elderly and their family members to project workshops and other relevant events. These events will provide the rural elderly with opportunities to express their opinions, and engage in the policy dialogue with the decision makers and academics. They will also be invited to comment on the draft of the plain language report, which will be disseminated to relevant parties.

4. Academics
Limited research has been carried out in the field of LTC in rural China. This research will raise the awareness of health and LTC research among Chinese and international scholars, bridge the research gap, provide new findings and call for more engagement in the field of health and LTC research in China.
 
Description We are in the process of finalising all academic deliverables of the project. Through the third year of the grant, this study has a number of key findings.
• The first finding relates to the current financing models for long-term care (LTC) in China. As the Chinese government is piloting new ways to finance its LTC sector, I have conducted a focused review of academic and grey literature, supplemented with qualitative interviews with government officials from relevant departments, care home staff and service users to assess different financing models that currently been used in China. Three emerging models are explored: Social Health Insurance (SHI) in Shanghai, LTC Nursing Insurance (LTCNI) in Qingdao, and a means-tested model in Nanjing. I find that, although SHI appears to be a convenient solution to fund LTC, this model has led to systematic bias in affordable access among participants of different insurance schemes, and has created a powerful incentive for the over-provision of unnecessary services. The means-tested method has been remarkably constrained by narrow eligibility and insufficiency of funding resources. The LTCNI model is by far the most desirable policy option among the three studied here, but the narrow definition of eligibility has substantively excluded a large proportion of elders in need from access to care, which needs to be addressed in future reforms.
• Using data from the China Health and Retirement Longitudinal Survey 2011, I investigated on inequity in LTC needs and access among the elderly in rural and urban China. I find that the rural elderly has significantly higher LTC needs and unmet needs compared with the urban elderly, and the rural poor are more likely to report poor health outcomes compared with the rural rich. The urban elderly, especially the urban rich, have started to use other types of LTC in addition to informal care, whereas LTC support in rural areas is still largely limited to informal care provided by family members.
• A paper entitled as Is informal care sufficient to meet the long-term care needs of older people with disability in China? Evidence from China Health and Retirement Survey is completed and is at R&R stage with Ageing and Society. Drawing data from the 2015 wave of the China Health and Retirement Longitudinal Survey, this paper explores the relationship between informal care provision and unmet long-term care needs among older people in China. We first examine the availability of informal care among older people with disabilities, we then look at whether a higher intensity of informal care leads to lower unmet needs. We further test the interaction effects between informal care intensity and cognitive function and their associations with unmet needs. Our findings suggest that the majority of older people with disabilities receive a low intensity of care, i.e., less than 80 hours per month. Besides, higher intensity of informal care has no association with unmet needs for the majority of the disabled older adults, except for a subgroup who are ADL dependent and have no cognitive impairment. We also find that the number of hours of informal care received has no significant effects on unmet needs. This means that even among the older people receiving a high intensity of care, the odds probability of them reporting having unmet needs, does not differ from those receiving a low intensity of care. Our study points out that informal care is insufficient to meet the growing needs and indicates a pressing need for the government to buttress the formal care provision and delivery systems to support these disabled older people in China.
• A paper entitled as Understanding non-medical costs for health care: Evidence from inpatient care for older people in China is also completed and is forthcoming at China Quarterly. This paper seeks to answer the third research question proposed in the grant - fairness in health and long-term care financing. This study seeks to examine the effects of non-medical costs (e.g. costs associated with travel, productivity lost, food, paying for carers) on catastrophic health payments and health payment-induced poverty among older people in rural and urban China. Using data from the China Health and Retirement Longitudinal Survey 2015, this study finds that inpatient costs account for a significant proportion of household expenditure, and non-medical costs can account for approximately 18% of total costs. That share is highest for those who belong to the lowest wealth groups. Non-medical costs increase the chances of older people incurring catastrophic health payments and suffering from health payment-induced poverty. Such effects are more concentrated among the poor than the rich. The results also show that the rural population are more likely to incur catastrophic health payments and suffer from health payment induced poverty compared to the urban population. This paper urges policy makers to consider reimbursing the non-medical costs of patient care, improving health care systems in general and for the rural populations specifically.
• A paper entitled as Care providers, access to care, and the Long-term Care Nursing Insurance in China: an Agent-based Simulation is published by Social Science and Medicine. In 2012, the Chinese government piloted one of the first publicly funded LTC nursing insurance (LTCNI) in developing countries with an aim to improve access to long-term care for older people in China. Although some early studies of the LTCNI showed that the scheme has been successful in meeting key objectives intended, most of these studies do not take into account the availability, price and quality of the local care providers, which may have significant effects on overall access to care. Using the LTCNI in Qingdao as a case study, this paper applies Agent-based Simulation approach to examine the effects of the LTCNI on access to care by considering factors associated with the local care providers. Our results show that there exist considerable discrepancies among the LTCNI beneficiaries in terms of access to services. Nursing home care use is more concentrated among the rich, whereas home-based care is more frequently used by the poor. We also find that the poor are more likely to choose nursing home with low costs albeit these services are often of poor quality. Despite a soaring demand for home-based services, our findings show that these services are often not distributed according to population needs in the localities. Unmet needs are high in districts with a large number of older people and limited services. We urge the policy makers to improve the overall design of the LTCNI, and to optimise the distribution of LTC services in districts with a high percentage of old population.
• We are also writing a perspective paper which is based on the 2nd Symposium on Ageing and Long-term Care in China was convened from 4 - 5th July 2019. The symposium is part of the deliverable of the grant. The symposium drew from a wide range of disciplines, including economics, public policy, demography, gerontology, public health and sociology. A total of 20 participants, spanning from 8 countries, sought to identify key issues and research priorities in the area of ageing and LTC in China. International lessons are also discussed in the symposium. In an era that witnesses an unprecedented pace of population ageing, it is essential for researchers to launch multidisciplinary research programs built on different disciplinary traditions that integrate a wide array of views, methods, and data to yield a better understanding on how to achieve an efficient and equitable LTC system in China as well as other developing countries. Lessons from the high-income countries, such as Germany, Japan, South Korea, in terms of understanding risk factors for age-related diseases, LTC service planning, financing as well as the application of technology in LTC, would be valuable for China. These top four research areas are proposed as key areas that could pave the way to many important inquiries, discussion, and future research priorities to examine challenging issues surrounding ageing and LTC development in China.
Exploitation Route Our impact strategy is informed by the principle of engaging and collaborating with different stakeholders at every stage. Potential beneficiaries and stakeholders of this research are listed as follows: Policy makers: This study provides evidence-based recommendations on the impacts and design of the health and LTC system to policy makers. Service providers: Study results from this research provide new evidence for service providers and help them to understand issues concerning health and LTC use and costs, as well as to identify areas on which they should focus. Older people and their family members: Older people and their family members will also benefit from this research as a health and LTC system with a thoughtful design is likely to have a positive impact on their use of LTC services and consequently their health outcomes.

I have started to disseminate the findings. A few activities have been implemented or planned:
• I attended a conference with Qingdao government official in December 2019. The conference includes a visit of a local care provider and a round table discussion with the provider, a conference and then discussion with government officials from Qingdao Civil Affairs and Social Security Bureau. The conference was organised by a member of the advisory group. I had chances to speak to the government officials and introduced the research project as well as to listen to their concerns on health and LTC system in Qingdao. We had fruitful discussions and agreed to continue to work together.
• Will attend a forum organised by Zhejiang University and China Health Policy and Management Society (CHPMAS) in July. I have arranged meetings with the former and current president of the CHPMAS - Zhuo Chen and Xi Chen to discuss further opportunities for collaboration and disseminate activities. CHAPMAS is one of the most influential organisations that links the academics with policy makers in China. To collaborate with them will result in a greater impact of the project and also be beneficial for the PI's career.
• The 2nd Symposium on Ageing and Long-term Care in China was convened from 4 to 5th July 2019 to discuss these topics. While the 1st symposium focused on key drivers for population ageing, such as increased life expectancy and low fertility, the 2nd symposium drew research insights from a wider range of disciplines, including economics, public policy, demography, gerontology, public health and sociology. A total of 20 leading researchers and scientists from eight countries, sought to identify key issues and research priorities in the area of ageing and LTC in China. International lessons were also discussed in the symposium. The participants discussed these four priority research areas: Understand risk factors on healthy ageing, improve access to care, Address issues in long-term care financing and promote technology and innovation in LTC.
Sectors Healthcare
 
Description The findings of the study will contribute to the debate of the LTC financing reform in China. Two project papers focuses on financing LTC in China. One of the papers assessed the performance of one financing model - LTC insurance. As the central government has decided to further expand the LTC insurance to fifteen cities in the affluent Eastern provinces as well as the less developed South Western and North Western provinces, this paper therefore empirically assesses the performance of LTC insurance in Qingdao with an aim to provide policy recommendations based on an improved understanding of the scheme. The findings in Qingdao are likely to inform the LTC financing policy in other metropolitan areas in the country. Furthermore, the findings generated from the third paper on urban/rural disparities in LTC needs and access urges the policy makers to take actions to address issues relating to unmet needs and serious shortage of home- and community-based LTC services, particularly in rural areas, and improve equitable access to LTC services. This is potentially important as LTC system has always been neglected in the rural governments' policy agenda.
First Year Of Impact 2016
Sector Healthcare
Impact Types Societal,Policy & public services
 
Title Developed an Agent-based model to simulate the effects of the long-term care insurance on equitable access to care 
Description My advisory group member and I have developed an Agent-based simulation module that can be used to predict the impact of the long-term care insurance on equitable access to care. In 2012, the Chinese government piloted one of the first publicly funded LTC nursing insurance (LTCNI) in developing countries with an aim to improve access to long-term care for older people in China. Although some early studies of the LTCNI showed that the scheme has been successful in meeting key objectives intended, most of these studies do not take into account the availability, price and quality of the local care providers, which may have significant effects on overall access to care. Using the LTCNI in Qingdao as a case study, we apply Agent-based Simulation approach to examine the effects of the LTCNI on access to care by considering factors associated with the local care providers. Our results show that there exist considerable discrepancies among the LTCNI beneficiaries in terms of access to services. Nursing home care use is more concentrated among the rich, whereas home-based care is more frequently used by the poor. We also find that the poor are more likely to choose nursing home with low costs albeit these services are often of poor quality. Despite of a soaring demand for home-based services, our findings show that these services are often not distributed according to population needs in the localities. Unmet needs are high in districts with a large number of older people and limited services. We urge the policy makers to improve the overall design of the LTCNI, and to optimise the distribution of LTC services in districts with a high percentage of old population. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? Yes  
Impact We think the tool can be used to predict the impact of the LTCNI on equity and efficiency locally using local demographic and socioeconomic data. As China is planning to rollout the LTCNI to 15 cities, this model can serve as a powerful policy tool for the policy makers in these 15 cities to make evidence based policy decisions on the design of the LTCNI. 
URL https://www.sciencedirect.com/science/article/pii/S0277953619306628
 
Title China Health and Retirement Longitudinal Survey (CHARLS) 
Description Commissioned by National Institute on Aging (U.S.), the World Bank and the National Natural Science Foundation of China, the CHARLS is an ongoing, publicly available, international collaborative project that collected a nationally representative sample of Chinese residents ages 45 and above. A total of 28 provinces/autonomous regions varying substantially in terms of geography, economic development, public resources and health indicators were included in the survey. The survey employed multi-stage sampling. First stratified by urban and rural community and then by GDP per capita, a population weighted sampling scheme was used to randomly select 150 counties. Three urban and rural communities (Primary Sampling Unit) were then selected within each county-level unit using Probabilities Proportional to Size sampling method. Households with persons aged 45 and above were surveyed, and the one who was aged 45 or above and his/her spouse were interviewed. The CHARLS is designed to investigate issues relating to health, economic position and quality of life as people age. It includes questions on socioeconomic status, i.e., gender, age, education, marital status, occupation, wealth, region, and ethnicity. It also has questions on health outcomes and health services utilisation, insurance coverage and health providers, and long-term care needs and use. 
Type Of Material Data handling & control 
Provided To Others? No  
Impact This data can be used in other studies relating to health and LTC in China. 
 
Description Collaboration with the Chinese Academy of Social Sciences on Qingdao Long-term Care Nursing Insurance Fieldwork 
Organisation Chinese Academy of Social Sciences
Country China 
Sector Academic/University 
PI Contribution One draft paper is pending submission to Social Science and Medicine. It is a collaborative work with academics from the Chinese Academy of Social Science and the Hong Kong University of Science and Technology. We conducted extensive fieldwork in Qingdao to investigate China's first long-term care insurance in June 2016. The first draft of the paper has finished. The main contribution of our team is to help to conduct literature review, design questionnaire and analyse the interview data.
Collaborator Contribution The main contribution of the Chinese Academy of Social Science (CASS) is to arrange the fieldwork, liaison with the local governments and relevant parties in Qingdao. The CASS has also contributes the interview data from fieldwork that they have collected previously for another paper that was published at Health Policy and Planning
Impact Published paper: Yang, W., He, J., Fang, L., Mossialos, E., (2016) Financing institutional long-term care for the elderly: Options for China, Health Policy and Planning Working paper: Financing long-term care in an ageing society: evidence from China's Long-term Care Nursing Insurance
Start Year 2016
 
Description Collaborations with the Hong Kong University of Science and Technology on Long-term Care Financing among the Elderly in China 
Organisation The Hong Kong University of Science and Technology
Country Hong Kong 
Sector Academic/University 
PI Contribution The analysis, data collection and first draft of the papers are written by me.
Collaborator Contribution The Hong Kong University of Science and Technology (HKUST) has advised on study design and finalised the paper. A panel entitled as Financing Long-term Care among the Elderly in Asia is accepted by the International Public Policy Association Conference 2017. The panel will be chaired by Professor Xun Wu - the director of the Public Policy Institute at the HKST and myself. Two papers from this grant will be presented at the panel, and this panel has also attracted a wide range of academic and non-academic presenters from Korea, Taiwan, Singapore and China. This can also be considered as a knowledge exchange activity.
Impact Paper accepted with minor correction Tan, S., Xun, W., Yang, W., (2016) Impacts of type of social health insurance on health service utilisation and expenditures: implications for a unified system in China, Health Policy Working paper Financing long-term care in an ageing society: evidence from China's Long-term Care Nursing Insurance (target journal: Social Science and Medicine) Conference panel Financing Long-term Care among the Elderly in Asia, International Public Policy Association Conference 2017.
Start Year 2016
 
Description International Public Policy Association Conference (Hong Kong 2016) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact A presentation was given at the conference on the three LTC financing models in China. The presentation was well-received, and the comments from the presentation was used to contribute to the revision of the journal paper.
Year(s) Of Engagement Activity 2016
 
Description Long-term care research conference (London 2016) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact A draft paper was presented at the International Long-term Care Policy Network Conference in London in 2016. The presentation was well-received, and the audience reported interest in future collaborations on relevant topics.
Year(s) Of Engagement Activity 2016