1. Introduction
The Chinese elderly population is facing unprecedented challenges in elderly care [
1]. Against the backdrop of deepening economic structural reforms, large-scale urban migration, persistently low fertility rates, and increasing female labor force participation, family structures are shrinking and becoming increasingly nuclear. This reality, coupled with the growing geographical distance between elderly parents and their children, is continuously challenging traditional family care models [
2]. In response to the trend of population aging, the Central Government and the State Council have implemented a series of plans and policies focusing on the “urgent, difficult, worrisome, and expected” livelihood issues of the elderly, aiming to construct a support and service system compatible with the aging process and continuously promoting the coordinated development of the aging cause and industry [
3,
4]. Despite the operation of the New Rural Pension Scheme launched in 2009, which integrated social elderly care into family care to compensate for its inadequacies, the level of protection it offers remains quite limited [
5]. If the extension of elderly people’s lifespans is also accompanied by long-term illness, then the associated medical and care costs will pose a significant burden on families and society alike [
6].
How can we ensure that more elderly people enjoy longevity and good health? In recent years, policymakers have prioritized creating a favorable social environment for elderly health. Policies such as the Healthy China 2030 Planning Outline and the 13th Five-Year Plan for the Development of National Aging-related Affairs and Construction of the Elderly Care System advocate improving health levels, enhancing health equity, and ensuring universal access to basic elderly care and public health services. Especially since the outbreak of the COVID-19 pandemic in 2019, there is growing consensus among all sectors on the need for integrating health factors into all policies, prioritizing people’s health in the development strategy, and refining relevant policies to comprehensively protect citizens’ health rights.
However, some scholars [
7] argue that research on health should not be limited to macro-level differences in healthcare, resource allocation, and policies. It should also consider “inequality” among individuals at the micro-level. Despite significant improvements in the population’s health since the Chinese economic reform, known as the “reform and opening-up”, health inequalities remain pronounced across urban–rural divides, regions, and social strata [
8]. When individuals exist within specific social structures and relationships, interactions between macro- and micro-factors lead to health disparities [
9]. Especially in the context of transitioning elderly care models, the interrelations among family support, social security for the elderly, and health inequality become less clear-cut. In this study, we addressed the following questions: What is the relationship between family support and social security for the elderly regarding health inequalities? What mechanisms link traditional family support and continually improving social security with health disparities among the elderly? How do family support and social security impact health inequalities differently across genders, ages, and regions? Compared with existing studies, as presented here, we uniquely incorporated the individual relative deprivation index from a micro-perspective, assessed the synergistic and substitution effects of different elderly care models on health inequality among the elderly, and explored the micro-level mechanisms behind these effects. The findings offer valuable policy implications for enhancing the elderly care security system and improving the health standards of the elderly population.
7. Discussion and Research Conclusions
In this study, based on data from the China Health and Retirement Longitudinal Study, we measured the health inequality among the Chinese elderly by using the Kakwani index of relative deprivation. We constructed an empirical model to systematically examine the impact mechanisms and heterogeneity of different elderly support systems on health inequality. Below, we report our findings and the conclusions drawn from them.
Firstly, access to elderly social security and receiving familial support significantly reduce elderly people’s sense of relative health deprivation in China. In our study, within the social security dimension, only the provision of senior benefits significantly suppressed relative health deprivation among the elderly, while participation in pension insurance initially increased this sense of deprivation. However, its effect became non-significant after accounting for temporal dynamics, which contradicts the research findings obtained by Been, J. et al. (2017) [
20]. First, the research findings may be influenced by sample selection, as different databases might lead to variations in the conclusions. Second, the time span of data collection is a critical factor: self-administered questionnaires allow for more flexible timing, potentially revealing more pronounced temporal effects. Lastly, in this study, we employed a simplified approach to variable setting by using participation in pension insurance as a measure of its impact on health inequality, without delving into the specific effects of pension amounts on health disparities. Regarding family support, financial and emotional backing from children notably lowered elderly people’s sense of relative health deprivation, while daily care did not affect it. This is in line with the observations by Graffigna, G. et al. (2021) [
13] on the general weakening of family service functions.
Secondly, enjoying social security benefits for the elderly and receiving family support can foster a more positive attitude towards aging among the elderly. Specifically, older individuals who used elderly services, had pension insurance, enjoyed senior benefits, and received financial and emotional support exhibited a more positive attitude towards aging. This finding partially aligns with Wang Liu Y.’s (2023) [
22] belief that emotional comfort has the most significant impact on elderly people’s self-perception of aging, followed by living and financial support, and is consistent with Smith J.’s (2022) [
25] observation that social security and children’s financial support can lead to positive changes in attitudes towards aging.
Third, the more positive an individual’s attitude towards aging, the lower their sense of relative health deprivation, with the former serving as a mediator between different types of elderly support and relative health deprivation. Enjoying senior benefits and receiving financial support and emotional comfort from children positively influenced the attitudes of the elderly towards aging, thereby reducing their sense of relative health deprivation.
Fourth, based on heterogeneity tests, we found the following: The inhibitory effects of financial support and emotional support on relative health deprivation among the elderly did not differ by gender. However, participating in pension insurance significantly increased relative health deprivation among elderly men, while elderly women showed a significantly lower level of health deprivation when enjoying senior benefits. Regardless of living in urban or rural areas, an increase in financial and emotional support significantly inhibited the sense of relative health deprivation among the elderly. In the dimension of social security for the elderly, the three variables no longer significantly affected the urban elderly but did so in rural areas, where the availability of senior benefits is significantly reduced, and pension insurance increased the sense of health deprivation. Social security for the elderly did not affect the younger elderly but started to show changes for the middle-aged elderly, among whom using elderly services and enjoying senior benefits are less common, and pension insurance increased their health deprivation level. For the older elderly, emotional support reduced their sense of health deprivation, while living support increased it. This is consistent with previous findings (Been, J. et al., 2017) [
20] indicating that pension increases have widened the health gap among middle-aged and younger elderly populations. In China, the pension contribution levels for rural elderly individuals are generally low, with the vast majority falling into the category of low pension income, which aligns with the current situation.
Although this study’s findings offer preliminary insights into the relationship between senior care and health inequality among the elderly, several limitations and areas for further exploration remain: (1) While the sample partially represents the Chinese elderly population, further verification is needed regarding its representativeness and the implications for the broader applicability of the findings. Moreover, despite efforts to control for temporal effects, their long-term impact on the findings deserves deeper investigation. Notably, the influence of pension insurance on the sense of health deprivation among the elderly is no longer statistically significant after controlling for temporal effects, indicating a need for further research into both its short-term and long-term impacts. (2) This study’s results indicate that economic and emotional support from children can effectively alleviate the sense of health deprivation among the elderly, whereas the effect of living support is less impactful. Other forms of familial elderly care support and their health implications for the elderly necessitate more in-depth research. Additionally, the mediating function of attitudes toward aging between elderly care support and the sense of health deprivation warrants further clarification in terms of its underlying mechanisms and extent. (3) Long-term follow-up studies are especially crucial for a comprehensive understanding of the long-term effects of senior care support on health inequality among the elderly. Given that cultural disparities may influence both senior care support and health inequality, cross-cultural comparative research could offer a more expansive viewpoint.
Health inequality is one of the key indicators for measuring the level of sustainable social development, and its existence and persistence have various negative impacts on sustainability.Firstly, at the socio-economic level, health inequality can lead to imbalances in the labor market, affecting economic growth and social productivity. In particular, health disparities among the elderly may limit their re-employment opportunities and work capacity, thereby impacting economic development and social welfare. Secondly, health inequality increases the public health burden. Uneven demand for medical resources may lead to inefficient resource allocation, exacerbating the financial strain on the healthcare system and potentially leading to a decline in the quality of healthcare services. Additionally, health inequality reflects the inequitable distribution of social resources, which may lead to social discontent and tension, affecting social stability and harmony. Especially in a populous country like China, health inequality may exacerbate social stratification between urban and rural areas, genders, and age groups, affecting social equity and justice. In terms of environmental sustainability, health inequality is closely related to environmental factors. Poor living and working conditions are often associated with higher health risks. This not only affects individual health but also poses a threat to the long-term sustainability of the environment. Lastly, in terms of intergenerational effects, health inequality may indirectly impact the growth environment and health status of the next generation by affecting the quality of life and mental health of the elderly, increasing the family burden, and affecting children’s education and development.
Therefore, addressing health inequality requires not only improving social security and pension services but also considering the feedback effects of policies and systems to achieve fairness and effectiveness in policy implementation, thereby supporting overall sustainable social development.
Policy Implications:
- (1)
Refine the social pension insurance system. The social pension insurance system is crucial to ensuring the basic livelihood and health of the elderly and is a key factor in bolstering their self-esteem and confidence. Continued investment and reform in elderly care services and preferential treatment for seniors are essential to expanding coverage, enhancing benefit levels, and improving the system’s sustainability and equity. This will meet the diverse needs of the elderly population, promoting economic sustainability by reducing the strain on labor markets and social welfare systems.
- (2)
Reinforce family support in elderly care. Support from family members is a vital aspect of traditional Chinese culture and an effective means to reduce health inequalities among the elderly. Promoting a culture of filial piety and encouraging children to provide economic and emotional support to their parents will foster family harmony and closeness. This not only respects the elderly’s autonomy but also safeguards their dignity and rights, contributing to social stability and harmony, which are cornerstones of sustainable societies.
- (3)
Foster a positive attitude towards aging. An individual’s attitude towards aging significantly mediates health inequalities among the elderly and is pivotal to their sense of well-being. Education and guidance for the elderly, including community health campaigns and mental health services, should be strengthened to help them develop a positive view of aging and recognize the value of life in their later years. This approach encourages active social engagement among the elderly, leveraging their strengths and potential, fulfilling their self-worth, and enhancing their societal contributions, which are essential for intergenerational equity and sustainability.
- (4)
Make health policies that account for diversity among the elderly. Given the varying health statuses and needs of the elderly based on gender, residence, and age group, targeted measures should be adopted in health policy and resource allocation. There should be an increased focus on health investments for women, rural seniors, and the oldest old to bridge the gap in health resource accessibility. These policies will address the environmental and social determinants of health, ensuring that all segments of the elderly population can contribute to and benefit from sustainable development.