Population ageing in China: crisis or opportunity?
The Lancet
Filial piety—respect for one's parents, elders, and ancestors—is a deep-rooted virtue in China. But rapid economic development, along with rising individualism and shrinking family sizes, has eroded the social status of older adults in China. This change is coinciding with a huge increase in the number of older people. Many countries face an increasingly ageing population, but China is now home to the largest population of older people in the world. In 2019, 254 million people in China were aged 60 years or older. By 2040, this number is expected to increase to 402 million, making up around 28% of the population. These changes have profound consequences for health in China, with a rising risk and burden of non-communicable diseases and a soaring demand on health and social care systems. How can China adapt?
The traditional care model of the younger generation caring for older people will not provide the solution. China's fertility rate has fallen continuously in the past four decades, despite the introduction of pro-natalist two-child and three-child policies. India will soon overtake China as the world's most populous country, and the Institute for Health Metrics and Evaluation predicts that China's population will fall by 48% from 2017 to 2100. Instead, as a new Commission published this week in The Lancetargues, embracing and enabling healthy ageing is key.
The Peking University–Lancet Commission on the path to healthy ageing in China takes an optimistic perspective, outlining how healthy ageing represents a huge opportunity for China. Led by one of the leading think tanks in China—the National School of Development of Peking University—in collaboration with international experts from a range of disciplines, it lays out a series of policies aimed at not simply addressing the country's population crisis, but rather unleashing the intellectual and vocational capacities of the older population and the whole of Chinese society.
To do so will require changes in how and where care is delivered. The health of the current older generation in China is often complex, and can involve a high prevalence of comorbidity and multimorbidity, with consistent health disparities between rural and urban areas, and between men and women. Hoping to address these challenges by simply expanding the number of geriatricians and nurses in large hospitals is both unrealistic and unfeasible. Instead, the authors call for a move from disease-centred care to person-centred care; care for older people should be primarily community and family based, rather than hospital based. Such a recalibration will entail a huge culture shift: many people in China go directly to hospitals when in need of health services, bypassing primary care.
The huge gap in long-term care services must also be filled. In an analysis published in The Lancet Public Health, Jinquan Gong and colleagues forecast that an extra 14·02 million older Chinese people will need long-term care by 2030. Therefore, the commissioners say, promoting the development of interdisciplinary primary health-care teams, integrated into the community, for older people is imperative, including the establishment of mobile health and online health services to improve access.
The need for change goes beyond the health system. The commissioners acknowledge that social and economic inequities are pervasive and dictate the health of older people in China. To ensure financial security for all, China should subsidise medical care and education for the poorest people, adopting a life-course approach to the social determinants of health, and narrow socioeconomic gaps (eg, between those living in urban and rural areas). For example, working class women retire 10 years earlier than men in China, resulting in substantially lower pensions and large gender inequalities. Raising the retirement age of women to that of men would help to reduce this disparity.
This is an ambitious set of recommendations, which apply across many sectors of Chinese society. They will not be fulfilled without strong political will. The importance of population ageing was recognised in the last month's National Congress of the Chinese Communist Party, where President Xi Jinping spoke of the construction of a healthy China, and the prioritisation of health. He vowed to actively respond to population ageing, develop the elderly care system, and ensure all older people in China can enjoy essential care and support. These are sensible priorities, given China's demographic trajectories. The Peking University–Lancet Commission brings together the best evidence and provides the clearest path to making them a reality. The result would be good not only for older people, but for the health of China as a whole.
