Analysis of the Current Situation Regarding the Aging Rural Population in China and Proposed Countermeasures

Abstract

China has become a country with an aging population. Compared with the aged in urban areas, the aged in rural areas have low income and are subject to social security deficiencies; the oldest among them are the most vulnerable group. If an effective mechanism for handling health risk is not available, the poor health of the rural elderly will cause an increase in their poverty level, which in turn will cause their health to become worse. Therefore, it is essential to analyze the current situation regarding rural population aging in China and to develop countermeasures. Data from 4 national health services surveys were used to analyze the differences between urban and rural populations. The results of the analysis revealed that the aged population in rural areas has poor health; economic security for the aged population is insufficient; and resources for the aged are lacking in rural areas. The Chinese government should improve medicare for the aged in rural areas, and establish a medical treatment subsidy system and a medical support system for the aged in rural areas. (Population Health Management 2012;15:181–185)

Introduction

G iven the rapid growth of the economy and improvement in the standard of living, the average expected lifespan has increased substantially, and the populations of many developed countries now include many elderly individuals. In 2008, there were 159 million people in China older than 60 years of age, accounting for 12% of the total population¹; China has become a country with an aging population.² The acceleration of rural population aging in China, the implementation of a birth control policy, the lengthening of the average lifespan, the exodus of young laborers from rural areas, and the shift in people's concept of life have resulted in more of society's attention being focused on the rural population. The aged are a vulnerable group in the construction of a harmonious society. Unlike other developed countries, China's health system does not offer every aged person good health care service. Compared with the aged in urban areas, the aged in rural areas have low income and are subject to social security deficiencies; the oldest among them are the most vulnerable group. If an effective mechanism for handling health risk is not available, the poor health of the rural elderly will cause an increase in their poverty level, which in turn will cause their health to become worse.³

Methods

The data used in this article were derived from 4 national health services surveys that were conducted in 1993, 1998, 2003, and 2008, and covered the urban and rural populations. In 1993, the Ministry of Health of China decided to conduct the National Health Service survey every 5 years to collect relevant information on utilization of and expenditure for health services, with the goal of helping Chinese policy makers in the Centre for Health Statistics and Information. The survey consists primarily of a household health interview survey and a health facility-based survey. The authors obtained the data from the Information Centre of the Ministry of Health of People's Republic of China. Data from 3 national health services surveys were used to analyze the differences between urban and rural populations. The data were analyzed using SPSS, version 11.5 (IBM, Chicago, IL) for Windows. A P value of < 0.05 was considered to be statistically significant.

Results

Characteristics of the aging rural population in China

The aged population in rural areas is in poor health. Both the illness rate and the hospitalization rate of the aged in rural areas are remarkably higher than in the general population, and most of the diseases are chronic. The rural elderly have low income, poor health, and a high illness rate; therefore, they have a high demand for medical treatment. The data from 4 national health services surveys show that the overall 2-week morbidity rate (the odds of becoming sick in 2 weeks) of rural residents was 128.2% in 1993 and increased to 176.7% in 2008, and has continued to rise in rural areas (Table 1). The prevalence of disease in the urban and rural elderly differs from the gap that had existed. As shown in Table 1, in 2008 the total prevalence in urban areas is 222.0%, compared to 176.7% in rural areas. Although it may appear that the 2-week morbidity rate of rural areas is lower than that of the urban areas, the reason for this lies in the gap between the two in available medical service. In rural areas, it is so inconvenient to see a physician that people will visit one only when they can no longer ignore the pain, which often occurs when the disease is at a severe stage. The inconvenience of physician visits causes people in rural areas—especially the aged—to refuse to go for medical treatment when they do not feel well. This has the direct effect of making the 2-week morbidity of rural areas lower than that of the urban areas. In both urban and rural areas, the prevalence of women's self-reported 2-week morbidity was higher than that reported for men (Table 1).

Table 1.

The Two-Week Morbidity Rate in Four National Health Services Surveys (%)

	Urban			Rural
Year	Male	Female	Total	Male	Female	Total
1993	158.0	191.8	175.2	118.7	138.1	128.2
1998	170.7	203.5	187.2	125.0	150.1	137.1
2003	142.3	178.7	160.9	135.1	158.1	146.5
2008	202.6	240.4	222.0	159.4	194.3	176.7

In addition to other factors, chronic diseases are major factors that influence the health condition of the aged,⁴ particularly diseases such as cardiovascular disease, diabetes,⁵ metabolic syndrome, and dementia, the incidences of which are increasing. The incidence rate for chronic diseases for various age groups is always high.⁶ However, data from the fourth national health service survey of family health show that the prevalence rate of chronic disease among the urban elderly was higher than that of their rural counterparts, and the differences were statistically significant (P<0.05; Table 2).

Table 2.

Prevalence Rate of Chronic Disease (%)

Year	Urban	Rural
1993	19.8	10.1
1998	18.2	9.7
2003	18.4	9.6
2008	25.9	15.2

The economic security of the aged population is insufficient. Social security is insufficient in rural areas because most females in rural areas have no economic income or economic independence; thus, the aged population (particularly the female aged population) tends to rely on informal support. There are 3 types of informal support: support from children, support from relatives, and support from nonrelatives. The latter type of support comes from 2 groups: (1) support from friends, neighbors, and colleagues, and (2) support from charity agencies, nongovernmental organizations (NGO), and volunteers. In addition, the Chinese aged population in rural areas has a low retirement rate and a small pension. This population has little likelihood of obtaining government subsidies, collective subsidies, or other subsidies given the low level of social security for the aged. Therefore, the aged population relies heavily on family members for economic support.⁷

The results of 4 national health services surveys show that the proportion of urban and rural residents covered by health insurance fell sharply from 29.7% in 1993 to 23.6% in 1998, and then increased sharply by 2008. Before 2008 the coverage in rural areas was significantly lower than in urban areas. With the implementation of a rural cooperative medical service established in 2003, insurance coverage has reached the highest rate in history. Participants in the rural cooperative medical service pay a small sum of money every year; the monies paid are held in a central fund. When participants of the rural cooperative medical service become sick, the money from the central fund is used to pay for their medical treatment. The medical service was created based on the current situation in China, and it covers many people. But many unfortunate issues exist with the rural cooperative medical service system. For example, people who are healthy or who only contract a minor ailment cannot submit their expenses for reimbursement; it is a waste of money for them to take part in the system. Conversely, those people who contract a serious disease are reimbursed for only a small part of the expense; the cost is far too expensive for them, despite their insurance coverage. Therefore, even though a higher percentage of people in rural areas have health insurance coverage, they still must pay an out-of-pocket co-payment. As a result, differences between urban and rural residents' insurance coverage remain. This situation may result in unbalanced economic development and differences in quality of life between urban and rural areas. The government's support of rural health care is insufficient and it results in the vast majority of people having to pay for their own health care (Table 3).

Table 3.

The Percentage of Urban and Rural Residents Covered by Health Insurance (%)

	Health insurance			Self-paid
Year	Urban	Rural	Total	Urban	Rural	Total
1993	55.1	21.0	29.7	44.8	79.0	70.3
1998	55.9	12.7	23.6	44.1	87.3	76.4
2003	72.7	15.9	30.1	27.3	84.1	69.9
2008	71.9	92.5	87.1	28.1	7.5	12.9

The fourth survey by the national health service of 56,456 rural households revealed that an average of 9.1% of family incomes were below the food poverty level in 2008. In order to meet the health service needs of family members, these families must choose between purchasing food and purchasing medical services. This leads to serious economic consequences, regardless of the choice made. A total of 10.6% of households had difficulty paying the cost of basic health services regardless of whether they had health insurance. Nearly 29.2% of families experienced difficulty paying for medical services.

The resources for the aged, such as care and support from their children, their economic security, support from the government and society, and information about disease, are poor in rural areas. Rapid urban economic development has resulted in a large migration of rural residents into cities. According to data from the National Bureau of Statistics of China, the migrating population in cities increased from 40 million to 200 million from 1990 to 2008; this population has had a significant impact on the availability of resources for the aged in rural areas. According to data from a 1-time sampling investigation of the situation of the aged in urban and rural areas of China, 48.9% of the aged population in rural areas are empty nesters.⁸ Therefore, the economic and social development, variation in family structure, and lack of social security have resulted in insufficient resources for the aged population in rural areas.^9,10

Influences on society of the aging rural population in China

Influence on the national economy

Statistics show that the outpatient and hospital costs of individuals older than 70 years of age in China are 5 times and 7.4 times greater, respectively, than the costs for individuals younger than age 69.¹¹ The percentage of individuals older than age 65 in the United States increased from 12.2% in 1990 to 12.8% in 1996, an increase of 0.6%, while health care expenditures paid for by the US government increased from 12.6% of the GNP to 14.8% of the GNP, an increase of 2.2%. This indicates that the greater health care expenditures that are a result of aging will have a significant influence on the national economy. Facing such pressure, it is evident that, as a developing country, China is unable to afford this level of expenditure. The total economic burden of disease in China was 1453.54 billion Yuan in 2008.

Health services challenges arising from aging population in rural areas

The aged are a vulnerable group in society, and their illness and hospitalization rates are remarkably higher than those of the general population. Most of the diseases of the aged are chronic; hence determining how to fully and rationally utilize the limited medical treatment resources in rural areas is a difficult problem. Many factors must be considered. For example, one must consider the decrease in the hospital bed turnover rate caused by prolonged hospital stays for the aged in light of the increasing demand for hospital beds; consider the large aged hospitalized population in light of the relatively insufficient numbers of medical staff; and consider the increase in medical treatment costs in light of the low economic income of the aged, among other issues.^10,12 The Chinese government put an end to the old type of medicare and began to reform the basic medical insurance system for urban workers in 1998. At the same time, the structural reform of business units also caused a large number of workers to be laid off, which directly led to the sharp decrease in the number of physician office visits since 1998. An increasing number of people in urban areas cannot afford the cost. The visit rate in rural areas stayed nearly the same, which indicates that the situation faced in rural areas did not change. The reason why the prevalence of SARS in 2003 directly made an obvious visit rate drop in both urban and rural areas is the lack of corresponding knowledge and hospitals; the facilities where SARS patients were isolated were regarded as dangerous places for people who were not and did not wish to be infected. Since the Chinese government started to reform the rural medical system in 2003, the physician visit rate has increased slightly. But the increasing hospitalization rate shows that people still only visit the physician when their disease reaches a severe stage, which cannot be treated easily in an outpatient clinic. The inconvenience and cost prevent the rural aged from visiting the physician when they have a mild case of illness. From 1993 to 2008, the average number of physician visits per day increased from 4.3 to 4.4, and the number of hospitalizations per day fell from 1.7 to 1.5. Table 4 shows that work efficiency (a standard that determines how effectively the work has been done) is very low, but the difference is caused by unbalanced medical resources. Urban doctors may have 20 patients to see per day, while rural doctors may see only 1 patient every 2 or 3 days, which causes the average efficiency to be low. A large gap remains between urban and rural medical services and much needs to be done in the future.

Table 4.

The Work Efficiency and Business of Hospitals in China

	Visit rate		Hospitalization rate			Average workload per physician
Year	Urban	Rural	Urban	Rural	Rate sickbed use (%)	Diagnoses /day	Inpatients /day
1993	19.9	16.0	5.0	3.1	62.7	4.3	1.7
1998	16.2	16.5	4.8	3.1	53.0	4.6	1.4
2003	11.8	13.9	4.2	3.4	69.4	5.0	1.5
2008	12.7	15.2	7.1	6.8	81.5	4.4	1.5

Discussion

Great efforts have been made by the Chinese government and society to improve the social services for the aged in rural areas. Until now, the aged in rural areas have lacked sensible health care service because of the absence of doctors and medical facilities. In particular, the rural cooperative medical system, which is one of the Chinese government's reform measures, has played an active role in providing medical treatment and health services to the rural population. The Chinese government has enacted other medical reform measures in addition to establishing the rural cooperative medical service, such as reducing the price for medicines and medical care, building different medical systems for different occupations, among others. The reforms have achieved some success so far but there still is much to be done, especially in the area of the rural aged. According to the sampling investigation on the aged population in urban and rural areas in 2000, only 1.896% of the aged have access to free medical services. Many of the aged fail to get necessary medical services because they lack the economic resources; the health needs of the aged in rural areas are not adequately met. Therefore, paying attention to the health needs of the aged in rural areas and establishing a health security system for the aged have become the most important tasks to solve the problems experienced by the aged in rural areas of China.

The current situation and proposed countermeasures

Implement and perfect a new cooperative medical system in rural areas

The new cooperative medical system indicates a perfect system that guarantees the aged having professional health care service. Health security for the aged is both an important aspect of total security for the aged and an integral component of the whole health security system. The development of health security for the aged in rural areas relies on social development, particularly the development of health services in rural areas. Given the current situation, implementation of the new cooperative medical system in rural areas must be actively accelerated. According to the planning done by the Ministry of Health of the People's Republic of China, the scope of the pilot area was expanded to cover 40% of counties in 2006, 60% in 2007, and basically the whole country in 2008; the goal of covering all rural residents was to be realized in 2010.¹³ These plans have been implemented. In such a process, the responsibilities of the government should be further reinforced. A problem that has arisen is that the billing rates of new cooperative medical system are too low because of low incomes and limited consumption. In addition to the organizing and supervising functions, the government should intensify the efforts for fiscal support in order to solve this problem.

In addition to the measures noted, the authors suggest that the following measures be taken:

Establish a medical treatment subsidy system for the aged in rural areas

Currently, the rural cooperative medical system is still in a recovery and development phase. With the restriction on billing, it is difficult to meet the health needs of the aged.¹⁴ The aged in rural areas have low income, poor health, high rates of illness, and high medical treatment needs. Therefore, it is necessary to establish a dedicated medical treatment subsidy system for this group, which should include preventive care in order to lower morbidity from chronic diseases. By doing this, the aged in rural areas would receive a basic level of health care and have a more stable life. The government should mobilize social resources by providing funds, policy, and technical support and should provide dedicated assistance and economic support for sick aged individuals who currently do not receive medical treatment because they lack economic resources. Establishing a medical treatment subsidy system for the aged could meet their need for medical treatment and could alleviate the economic risks caused by the diseases that affect the aged and their families.¹⁵

Establish a medical support system and assign medical staff to hospitals in villages and towns

The technical level of medical treatment in rural areas could be improved by assigning urban medical staff to support rural hospitals using a rotation system, which could accelerate the harmonious development of health services in urban and rural areas. Grassroots organizations for the aging, which aim to safeguard the rights and interests of the elderly and help them have better quality of life, should be established in rural areas. These organizations should provide assistance to solve specific problems and resolve difficulties faced by various aged groups.¹⁶

Strengthen the health services for the aged in rural communities

An economical method to solve the medical treatment problems of the aged is to intervene in multiple areas (eg, society, environment, physiology, psychology) to reduce disease prevalence.¹⁷ In addition, the community health care system should be intensified.¹⁸ Because of the decrease in the number of children and the increased mobility of populations in rural areas, the aged in rural areas have fewer children upon whom they can rely. Many of the aged are lonely without children to look after them, and many empty-nest households have appeared.¹⁹ Deficiencies in economic support and care may occur if an aged individual living in an empty-nest household is sick. First, the government should increase the budget for medical services, especially in the medical institutions in rural areas, so that the lack of health resources in rural areas can be effectively improved. Second, policy makers should adjust the allocation of rural health resources in order to solve the problem of unbalanced health resources distribution. Last but not least, the investment in prevention and health care, such as infrastructure construction, should be increased to counter the serious lack of prevention funds available in rural areas, so as to ensure the normal operation of public health service networks in rural areas, to strengthen the development of prevention and health service staffs for rural areas, and to improve the level of technical skill. Prevention of and treatment for the common diseases of the aged is necessary, with an emphasis on prevention.^20
–22 Because preventive measures will have a great impact on the implementation of the whole program, it must be a high priority.

Increase health care knowledge and strengthen awareness of self-care

According to the health service investigation data of China in 2003, a negative correlation exists between educational background and any hospitalization within 2 weeks. The investigation results with regard to the aged population in China in 2000 indicate that 61.6% of the aged in rural areas have had no formal education, and 25.8% of the rural elderly have the equivalent of a primary school level education²³; thus, a significant portion of the rural population has no secondary school education. In rural areas, 82.9% of the females have never been to school. Furthermore, the age of the elderly shows an inverse relationship with educational background. In rural areas, 46.3% of those who are older than 65 years of age have never attended school; 78.8% of those who are older than 85 year of age have never attended school. The low educational level indicates that the aged in rural areas lack awareness and knowledge about health and medical treatment. It also has been found that the aged in rural areas have bad habits that lead to a higher disease prevalence.

Therefore, the authors suggest the following measures be taken to popularize health care knowledge and to strengthen awareness of self-care. Health education for the aged should be instituted, with a focus on chronic degenerative aging conditions, so as to improve health knowledge among the aged²⁴; to allow the aged to understand the prevalence of, preventive methods for, and means of rehabilitation for common diseases; to assess patients' knowledge about symptoms of common diseases, the variables that may be associated with that knowledge, and to understand the need to seek early prevention and early treatment.²⁵ It is imperative that changes in lifestyle be made within this population to reduce the risk factors for common chronic conditions. There should be a focus on the general knowledge with regard to the prevention and treatment of common diseases of the aged; rational drug use; hygienic living; hygienic nutrition, diet, and spirit. Particular attention should be paid to strengthening the awareness of self-care of the aged. In addition, flexible and diversified means should be employed according to the actual situation of rural residents and the aged.²⁶

Increase the funding for social security for the aged and strengthen the implementation mechanism

With the continuous growth of Chinese fiscal revenues, the task of industry supporting agriculture and cities supporting rural areas should be implemented in a timely manner, and the money should be raised using various channels, such as government expenditures, collective subsidies, individual contributions, tax reductions and exemptions, and social donations. Regarding allocation of funds, living subsidies similar to the “Minimum Living Standard Security,” which provides the basic necessities of life for people, should be regularly allocated to the poor aged populations in rural areas to improve their living and health-related conditions.

Footnotes

Author Disclosure Statement

Drs. Qu, Li, Liu, and Mr. Mao disclosed no conflicts of interest.

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