Private vs public – who will care for China’s elderly?
- Government-run nursing homes are affordable but applicants face long waiting lists
- Authorities are hoping private players can bridge the gap but conditions and prices vary widely
The biggest thing Chinese retired electrical worker Zhang Guancheng misses is being able to wander around parks and chat with his old friends.
Since the 83-year-old widower moved into a nursing home in Wuxi, in the eastern province of Jiangsu three years ago, Zhang has had to surrender that simple pleasure.
“Life here is scheduled. They make sure I don’t hurt or die, but no one cares much whether I am happy or, most of the time, lonely,” he said.
Zhang had a stroke in 2018 and his only child, son Zhang Hu, was worried that his father would not be able to look after himself living alone.
“He had difficulty dressing himself and cooking after the stroke,” Zhang Hu said. “My wife and I both have to work and there is no one there keeping an eye on him. What if he fell? What if he had another stroke?”
A nursing home seemed to be the best option so Zhang Guancheng moved into the private facility, sharing a room with two others – one paralysed and the other unable to eat on his own.
In one sense, the family is fortunate. Places in nursing homes are few and far between, and private facilities can be expensive.
Zhang Guancheng is one of the roughly 190 million people aged over 65 in China. The age group accounts for 13.5 per cent of the country’s population, a proportion that is projected to rise to 30 per cent by 2050.
More than half of those seniors are living in “empty nests” – a household with only one person (11 per cent) or an elderly couple living without children, according to the National Health Commission.
Most of the responsibility for caring for the elderly falls on the immediate family, with only 3 per cent of the age group opting for nursing homes.
Part of the problem is the lack of places. According to the Ministry of Civil Affairs, there were 220,000 registered nursing institutions and facilities for the elderly by 2020, with over 7.9 million beds.
The number of beds has grown steadily but it has failed to keep pace with needs, dropping from 31.6 beds per 1,000 seniors in 2016 to 30.5 in 2019. The aim was to reach 35-40 beds per 1,000 seniors by 2020, under the national five-year plan released in 2016.
It means that families have to wait for months, sometimes years, to get a place.
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Zhang Guancheng was put on waiting lists for several nursing homes in his area before one of them called and offered a bed after two months.
The family chose the shared room to save on costs but it is still a strain on their finances.
Zhang Hu and his wife together make less than 100,000 yuan (US$15,400) a year but now 40,000 yuan must be set aside for the father’s care. They also have a daughter in university to support.
A government-run home would have been cheaper – 1,000-3,000 yuan a month – but it can be years before a bed becomes available.
According to a report released by Everbright Securities in 2019, Beijing’s No 1 Social Welfare Home, one of the leading facilities in the country, had 1,100 beds but more than 10,000 people were on the waiting list.
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At Zhang Guancheng’s nursing home, each member of staff – many of whom are women in their 50s and 60s – must care for six residents during a 12-hour shift.
He said that some of the residents, particularly those who were paralysed or who struggled to walk, were restrained in their beds and wheelchairs as the staff attended to others. Understaffing also meant that few residents had access to physiotherapy, he said.
The central government is banking on the private sector taking up even more of the slack. The Communist Party’s Central Committee and the State Council said in a joint policy paper in 2019 that China would “fully open up the elderly care market” and let private capital to fill the need.
But conditions vary widely in the for-profit sector.
In Suzhou, primary school teacher Wen visits her parents at a retirement community where staff are on call around the clock, a hospital is close by and residents can grow vegetables in plots in the grounds.
To move in, the family had to pay more than 1 million yuan for a 75 sq m (807 square feet) flat in the community. They also have to pay 8,000 yuan each month in fees, which cover breakfast and lunch.
“Only with a stable, high income, or with a high pension – in our case, that of a retired engineer and a retired accountant – can one family afford such care,” Wen said, declining to give her full name.
My wife and I both have to work and there is no one there keeping an eye on him. What if he fell?
Further up the market, premium care services are becoming more of a finance product in for-profit nursing homes backed by insurance giants and real estate moguls.
At the Qianhai Warm Care Home, a high-end nursing home in the southern city of Shenzhen, the minimum monthly payment is 10,110 yuan for a standard room, excluding a “care fee”, which can be as high as 9,800 yuan a month.
In addition, families need to buy a 2 million yuan (US$309,000) insurance product from its holding company Qian Hai Life Insurance, or pay 600,000 yuan (US$93,000) as a one-time deposit to obtain a residence permit.
After three years in operation, the home’s vacancy rate is still 70 per cent.
“We are not in a rush to admit more,” a customer service representative said. “It is not worth it if we lower the 2 million bar to let more people in. It will compromise our high-end brand positioning.”
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Huang Wenzheng, a demographer and fellow at the Centre for China and Globalisation in Beijing, said the private sector was not the answer to the growing demand for elderly care.
Huang said that only the government could fundamentally address the burden of elderly care by establishing close links between hospitals, communities and households.
“One can not expect such high-end private nursing homes to cater to the appetite of the whole population,” he said.
He said the one-child policy was “a structural factor that led to the dilemma of elderly care today” as the number of children born each year dwindled from 28 million to 14 million.
“Today we notice the workforce shrinking and a declining speed of economic growth. This is part of the legacy of the one-child policy, and it will live on, even deteriorate,” Huang said.
Yi Fuxian, a senior scientist at the University of Wisconsin-Madison and vocal critic of China’s previous family planning policy, is just as pessimistic about prospects of better care for seniors.
“The high cost of elderly care – whether offered in families or in care homes – is eventually borne by the next generation,” Yi said.
