Unveiling the Evolution of Eldercare Facilities in Rural China: Tracing the Trajectory from Eldercare Support Pattern and Service to Facilities for the Aging Population
Abstract
:1. Introduction
2. Eldercare Facilities in Rural China
- Rural nursing home/‘Wubao’ service institute. Nursing homes, the earliest form of eldercare service facilities, were established in rural China in 1956 and developed based on the ‘Wubao’ system (‘guarantees’ of providing five kinds of fundamental necessities including clothing, food, shelter, transportation, medical care, and end-of-life arrangements for older persons without labor ability, income, or children) during the period of the collective economy [30,36]. Policy advocacy during the era of the People’s Commune led to nursing homes seeing remarkable growth; by 1959, 150,000 such facilities across the nation had taken in over 3 million older individuals who were widowed or alone. Due to inadequate management after three years of natural disasters and the Cultural Revolution, many nursing facilities were repurposed for agricultural production or ‘Huazifang’ (rooms occupied by beggars) and did not begin to recover until the Household Contract Responsibility System was launched. A significant step in the standardization and formalization of nursing homes, in line with the ‘Wubao’ system, was taken in 1997 when the Interim Measures for the Management of Rural Nursing Homes established their clients, economic source, management, and operational structure as a rural collective welfare institution. The Decision of the Central Committee of the Communist Party of China and the State Council on Strengthening the Aging Work (2008) pushed conditional nursing facilities to open to all seniors but still prioritized ‘Wubao’ seniors. The nursing home’s dependence on subsidies from the government or collective is intricately linked to its target demographic and characteristics, making it especially susceptible to changes in the political environment; they have experienced a cyclical trend of growth, decline, stabilization, and institutionalization, which has been shaped by policy interventions during the People’s Commune, economic challenges arising from prolonged natural disasters, and the adoption of the ‘Wubao’ system by township governments operating under the Household Contract Responsibility System.
- Rural ‘Starlight’ senior center. China’s Ministry of Civil Affairs launched the Community Senior Welfare Services ‘Starlight’ Program in 2001 on a national scale with the aid of 20% of the welfare lottery revenue as financial assistance. From 2001 to 2004, a total of CNY 13.4 billion was invested in building 32,000 ‘Starlight’ senior centers. It was believed at the time that more than 30 million seniors would benefit from the services of recreational activities, home visits, first aid, nursing intervention, or medical care provided by the centers [32,37]. Zhejiang Province stood out as one of the few regions that offer specific construction guidelines for ‘Starlight’ senior centers situated in rural areas, as opposed to the majority that adhered to the construction norms that are commonly applied in urban contexts. Currently, following the extensive implementation of home-based care, the majority of rural ‘Starlight’ centers have been repurposed as daycare institutes, while some have not undergone renovations and have been plagued by unsustainable financial input, being occupied by private or misappropriated use.
- Mutual support ‘Happiness Home’ (MSHH). In 2008, a facility for mutual aid among older villagers was initiated in Qiantun Village located in Hebei Province. It is a self-managed and mutual aid facility for the older villagers in which inhabitants share the cost of public utilities and daily living expenses. It was officially promoted by the government in 2011 with the name ‘Happiness Home’ since it embodies the ‘Antuzhongqian’ tradition (settling down in the place in which one has long lived) and local collective and government economic realities. In 2013, the Ministry of Finance and the Ministry of Civil Affairs issued the Project Management Measures for the Central Special Lottery Public Welfare Fund to Support Rural ‘Happiness Homes’, backing the construction of rural MSHHs with national finance. As of 2014, a total of 79,521 MSHHs have been established in rural China [38]. Currently, these facilities may not necessarily be named ‘Happiness Homes’; they are called elderly mutual aid centers in Guizhou or are part of ‘Mulindian’ (neighborhood points) in Shanghai.
- Rural home-based daycare service center. In 2008, the National Office for Aging of the Ministry of Civil Affairs issued the Opinions on Comprehensively Promoting Home-based Eldercare Services, which mandated the establishment of a comprehensive senior welfare service facility that integrates institutional care, home-based care, and community care in rural communities by leveraging existing facilities and resources. This is one of the main types of eldercare facilities promoted in rural China after communityization. The national standards for home-based daycare service centers largely apply to urban communities rather than villages when it comes to construction requirements. A few regions, like Zhejiang, have established village-level guidelines for these facilities. It was not until 2023 that rural home-based care service facilities had their first nationwide design standard.
- Rural clinic/health service center. The first National Health Work Conference in 1950 proposed the establishment of collective-owned joint clinics in rural areas, as well as the establishment of health centers in counties, districts, and administrative villages, forming a three-level network of healthcare services. In the agricultural cooperation period, various regions successively launched the construction of farmer-funded and collectively owned health stations, as well as health and medical stations established by agricultural cooperatives. During the period of the People’s Commune, those institutions and manpower were integrated into the commune’s healthcare system. The health centers in townships were integrated into the health stations managed by production brigades, and to facilitate farmers’ access to medical care, each production team had a clinic. Later, the three-level organization composed of commune hospitals, health stations of the production brigade, and clinics of the production team was determined by the Amendment to the Regulations on the Work of Rural People’s Commune, Draft Opinions on Adjusting Rural Basic Health Organization and other documents, with the principles of decentralized, small, and multi-point settings proposed. Rural clinics were given their roles of preventive care, primary diagnosis, and treatment of common injuries and diseases within the rural healthcare service network. Since the construction of rural communities began, most of the clinics have been renamed as health service centers.
3. Interpreting the Evolution of Eldercare Services in Rural China
3.1. Evolution of Eldercare and Public Service Support Pattern Services in Rural China
3.2. A Framework from Support Patterns and Service Delivery to the Eldercare Facilities in Rural China
4. Discussion: The Past, Present, and Future of Eldercare Facilities in Rural China
- The standardization of eldercare facilities surpasses the current economic development. Existing construction standards for rural eldercare facilities exhibit a lack of clarity regarding functional positioning, with a tendency towards incomplete functional settings and high construction requirements. Specifically, the construction standards for rural nursing homes catering solely to the ‘Wubao’ seniors even surpassed those for more metropolitan communities, plainly exceeding the capacity dictated by the level of rural development. As a result, most rural nursing homes were inclined to keep the activities that call for less space and services, such as recreational and outdoor activities, and reduced difficult-to-implement functions that require more resources, both material and human, like rehabilitation. This issue may also be attributed to the absence of clear positioning for each eldercare facility, including its role in providing public services in conjunction with other public facilities and its interaction with the rural public space system. As a result, despite having different categories, the constructed eldercare facilities lack diversity. The disparity and disorder arising from high construction standards but substandard construction, coupled with high service demands but prevailing unaffordability, led to a surplus of 475,000 unoccupied beds in rural nursing homes, with a utilization rate of only 78%.
- The availability of resources for the older population residing in rural areas remains inadequate, particularly concerning healthcare services. Several research studies have highlighted the insufficient benefits of primary healthcare services in rural communities. This is evident in the scarcity of standard medical diagnostic equipment, such as blood or urine tests, in specific township health centers, as well as the fact that unlicensed healthcare personnel is prevalent, with a rate exceeding 30% in urban health centers and 75% in rural clinics [59]. In addition, eldercare facilities and amenities suffer from a lack of continuous funding. This is especially problematic for the ‘Starlight’ senior centers, which depend on welfare lottery funding. The lottery monies were used as a transitory, one-time investment without market-based operational measures to improve fund utilization; thus, such facilities were susceptible to disorder and deterioration.
- The current political system presents a hindrance to the efficient distribution of resources. A critical concern that requires attention in rural senior facilities is the sustainability of operations post-construction. It is important to recognize that while there is a continuous demand for financial input, relying solely on government assistance is not feasible, especially in the rural context. Locating the facility’s identity in the administrative and resource provision system is the first and essential step in activating its own operational capacity, which can help rationalize the distribution of the object demands to be satisfied in accordance with the resources available to the various eldercare facilities in a system. This approach mitigates the inefficient replication of building and subsequent functioning, while also addressing the potential hindrances to capital investment arising from the institution’s equivocal character. For example, the regulatory framework pertaining to rural nursing homes lacks clarity, as observed in the Regulations on Rural ‘Wubao’ Services. The aforementioned regulations assign management responsibilities for the nursing homes to both the Civil Affairs Bureau and the township government. The lack of clarity in the management function has led to functional misalignment, an unclear division of authority and responsibility, and increased burden on townships in managing rural nursing homes. Moreover, it renders rural nursing homes incapable of accepting social donations as independent institutions.
- The passive shift of responsibility for eldercare services. The dearth of formal services in eldercare facilities has necessitated compensation from informal, non-professional services. For instance, the eldercare services promised in the norms of nursing homes, the ‘Starlight’ senior centers, and home-based senior care service centers are severely lacking in actual operation, whereas happiness homes have shifted the majority of senior care responsibilities back to the older villagers themselves from the start. Consequently, older residents had to rely on self-assistance and mutual aid to address the gaps in service provision. Furthermore, the absence of a specified target population in the requirements guiding eldercare facilities, coupled with the passive and autonomous nature of their operations, has resulted in a dearth of professionalism in the services provided. This has led to a lack of acceptance of older individuals most in need of assistance, including those with diverse physical conditions, those requiring assistance with self-care, as well as those with disabilities and paralysis.
- The inhibition of traditional cultural concepts regarding institutionalization. The evolution of rural eldercare facilities reveals that they have traditionally been associated with nursing homes for the ‘Wubao’ seniors, a perception that is commonly linked to destitution and abandonment in the minds of rural inhabitants. Rural seniors show a lower acceptance of external assistance compared to their urban counterparts, being less inclined towards relying on institutional care or other care alternatives. Furthermore, they exhibit a reluctance to express their ‘real’ demands, thereby posing challenges to a demand-based provision of eldercare services and facilities.
- A discrepancy exists between the supply of eldercare services in rural areas and the corresponding demands. The seemingly contradictory status quo of vacancy and absence actually reflects the lack of awareness of the rural situation and the needs of the older villagers during the pre-construction period. The absence of appropriate construction standards has led to the majority of construction specifications for rural eldercare facilities being mere replicas of urban specifications. This approach failed to cater to the unique requirements of rural seniors and the distinctive features of the rural environment, resulting in a mismatch between the available resources and the actual needs [60].
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Eldercare Support Patterns | Eldercare Services | Healthcare Services | |
---|---|---|---|
1949–1953 | Self-organization before Collectivization | ||
Self-reliance, family care, and mutual assistance among the village | Not applicable; mutual assistance among older villagers | Fund-raising by villagers, agricultural cooperative, and doctors | |
1954–1959 | Social welfare fluctuated with Collectivism Self-reliance and family care supported by the commune; minimal coverage and basic social welfare for ‘Wubao’ seniors | The formation of the dual structure between urban and rural places under the People’s Commune System Only basic support covering ‘Wubao’ seniors under the People’s Commune System | Exploration and practice of Rural Cooperative Medical System Parallel exploration of health service supply by the government and people themselves; the three-level Rural Cooperative Medical System based on People’s Commune; rapid increase in number of healthcare institutes in rural areas |
1960–1977 | Fluctuation of RCMS and the domination of barefoot doctors Self-sufficiency of healthcare services and medicine under the absence of Rural Cooperative Medical System; clinics and medical stations occupied by ‘barefoot doctors’ | ||
1978–2005 | Revival of social welfare after the reform of Household Contract Responsibility System Self-reliance and family care supported by a limited pension security; minimal coverage and basic social welfare for ‘Wubao’ seniors | The aggravating of dual structure under the Village Committee System Very limited public services covering a wider range of people provided by institutions | The trial and revival of RCMS The revival of RCMS; establishment and wide coverage of New Rural Cooperative Medical System (NCMS) |
2006–2008 | The breakdown of dual structure under the community system Expanding the source of service; improving the equalization of public services between urban and rural areas | ||
2009- | Multi-path exploration since the inception of building harmonious socialist society Self-reliance and family care supported by an expanded pension security; developing social welfare covering a wider range of people supported by multiple subjects | Systematization and equalization of public healthcare service Merging healthcare services between urban and rural areas; combining of eldercare and healthcare |
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Zhang, Z.; Wang, Z.; Qiu, Z. Unveiling the Evolution of Eldercare Facilities in Rural China: Tracing the Trajectory from Eldercare Support Pattern and Service to Facilities for the Aging Population. Healthcare 2023, 11, 2474. https://doi.org/10.3390/healthcare11182474
Zhang Z, Wang Z, Qiu Z. Unveiling the Evolution of Eldercare Facilities in Rural China: Tracing the Trajectory from Eldercare Support Pattern and Service to Facilities for the Aging Population. Healthcare. 2023; 11(18):2474. https://doi.org/10.3390/healthcare11182474
Chicago/Turabian StyleZhang, Ziqi, Zhu Wang, and Zhi Qiu. 2023. "Unveiling the Evolution of Eldercare Facilities in Rural China: Tracing the Trajectory from Eldercare Support Pattern and Service to Facilities for the Aging Population" Healthcare 11, no. 18: 2474. https://doi.org/10.3390/healthcare11182474