China is now facing a rapidly aging population. Between 2015 and 2050, the number of people aged 60 years and over will more than double from 222 million to 480 million . In addition to the enormous size of the elderly population, the number of older people with disabilities and chronic disease is significant. There were an estimated 40.6 million older people with disabilities in China in 2015, and this number is expected to reach 96 million in 2050 . Older people are more likely to have chronic diseases such as stroke, cardiovascular disease, diabetes, hypertension, and Alzheimer’s disease or related dementias, and have multiple comorbidities. According to official data, there were 180 million older people with at least one chronic disease in 2018, which was 75% of the total older population .
Population aging is one of the key drivers reshaping health care systems all over the world. The presence of multiple disease conditions and physical frailty makes disabled older people complex cases who require treatment and care at various health and care settings and specialties . A holistic approach to integrated care needs to consider not only integration inside the health sector but also the integration of social services . Ensuring the coordination and continuity of health and care is necessary for the elderly as it enhances the quality of care and patient experience and is more cost-effective . However, there are many challenges in care integration, especially between health and care, because the financing, provision, and regulation is usually separated .
In China, as in many other countries, health and care have been separated and fragmented. The main regulatory body for social service is the Ministry of Civil Affairs (MCA), while health care is under the supervision of the National Health Commission (NHC). This posed great challenges for the coordination and integration of health and care, resulting in many unmet needs and misallocation of resources. In order to promote care integration, the Chinese government has carried out a series of policies and efforts in the past decade. The aim of this paper is to review the reforms and progress of these efforts, examine lessons learned, challenges remaining, and propose further policy considerations.
China was formally labelled an aging country in 2000 when the population aged 60 and over reached 10% of the total population . As the country with the largest aging population in the world and now confronting the inability of its traditional bedrock, the family, to care for the elderly, China has embarked on building a formal elderly care system . The central government outlined a plan for a three-tiered elderly care system in 2005, which emphasized home-based care as its foundation, backed by community-based care and supplemented by institutional care . In late 2000s to early 2010s, there was a “leap-forward” development in institutional care, with the total number of residential care beds increasing from 1.54 million to 6.73 million from 2006 to 2015 . Although the demand for nursing home beds is surging, the occupancy rate showed a downswing during this period . This can be attributed to multiple reasons , and the lack of professional medical and nursing care is an important one . For example, it was reported that the occupancy rate of elderly care institutions containing medical clinics was over 75% in Beijing at the end of 2016, while the average occupancy rate of those without medical services was less than 30% . The integration of health has become an inevitable choice for elderly care facilities.
In terms of health care, a universal medical insurance system was established in China after the major healthcare reform in 2009  and the demand for medical services has been released. However, due to the lack of availability of aftercare, medically stabilized patients who need rehabilitation or extended nursing care had to remain in hospitals unnecessarily (i.e. social hospital stays) , or be re-admitted frequently, leading to the heavy use of the hospital resources and escalating health care costs [17, 18]. As a result, in the three-tiered medical system, large tertiary hospitals are often preferred by patients when they are hospitalized, with the bed utilization rate reaching full capacity in 2013 . However, some secondary hospitals had insufficient occupancy because of their limited professional skills and technical support. These are expected to transform into aftercare facilities, such as geriatric hospitals, rehabilitation hospitals, or skilled nursing facilities to receive patients discharged from large hospitals .
In response to the above issues, the Chinese government has come up with a series of policies since the early 2010s (Table 1).
|DOMAIN||POLICY DOCUMENT(S)||DEPARTMENT||TIME||MAIN CONTENTS|
|Service delivery||Basic Standards for Skilled Nursing Facilities (2011)||MOH||2011.03.21||Stresses the role of skilled nursing facilities as an important part of the health care system; specifies the service contents and standards of skilled nursing facilities|
|Basic Standards for Rehabilitation Hospitals (2012)||MOH||2012.04.25||Proposes specific construction standards of Rehabilitation Hospitals|
|Several Opinions on Accelerating the Development of Elderly Care Services||State Council||2013.09.06||Encourages medical services to be provided in elder care institutions, communities and families, and requires medical institutions to better provide chronic disease prevention|
|Guiding Opinions on Promoting the Integration of Health and Care Services||NHFPC & MCA, etc.||2015.11.18||Defines the goals and proposes the main forms and supporting measures of integration|
|Notice on Facilitating the Licensing of Integrated Health and Care Institutions||MCA & NHFPC||2016.04.08||Strengthens intersectoral cooperation to create a “barrier-free” environment for registration of new institutions|
|Guidance on Promoting the Family Physician Contracted Services||State Council||2016.05.25||Requires “family physician-led teams” in community health institutions to sign contracts with residents and provide them with services including basic medical care, public health and certain health management services|
|Notice on the First Batch of National Level Pilot Units for the Integration of Health and Care Services||NHFPC & MCA||2016.06.16||Selects 50 cities (districts) as the first batch of national level pilot units for the integration of health and care services|
|Notice on the Second Batch of National Level Pilot Units for the Integration of Health Care Services||NHFPC & MCA||2016.09.14||Selects 40 cities (districts) as the second batch of national level pilot units for the integration of health and care services|
|Basic Standards and Management Standards for Rehabilitation Medical Centers and Nursing Centers||NHFPC||2017.10.30||Encourages private sector to establish community-based rehabilitation and nursing facilities|
|Notice on the Replacement of Administrative Approval with Registration for the Establishment of Medical Institutions within Elder Care Institutions||NHFPC||2017.11.08||Cancels the administrative approval required for establishing medical facilities within elder care institutions, to be replaced by registration|
|Financing||The Plan for Deepening the Reform of the Health Care System during the 12th Five -Year Plan Period||State Council||2012.03.14||Encourages commercial insurance companies to develop long-term care insurance products actively|
|The 13th Five-Year Plan for National Economic and Social Development||State Council||2016.03.16||Proposes to “explore building a LTC insurance system” in this period officially|
|Guiding Opinions on Launching the Pilot of LTCI System||MHRSS||2016.07.08||Launches LTCI pilots and selects 15 cities across the country as the first batch of national pilot cities|
|The 13th Five-Year Plan for the Development of National Elderly Care Cause and Elderly Care System||State Council||2017.02.28||Encourages commercial insurance companies to develop long-term care insurance products and services to meet the diversified and multi-level needs for long-term care of the elderly|
|Guiding Opinions on Expanding the Pilots of LTCI System||NHSA etc.||2020.09.16||Expands LTCI pilots to 49 cities|
Aftercare facilities refer to post-acute or long-term care facilities providing rehabilitation, nursing and some medical support after patients are discharged from acute care hospitals. These have been scarce in China for a long time. As of 2010, there were only 268 rehabilitation hospitals and 49 skilled nursing facilities across China , causing a huge gap between supply and demand. To promote the development of these facilities, the current Ministry of Health (MOH) promulgated a policy document of “Basic Standards for Skilled Nursing Facilities” in 2011 , stressing the role of skilled nursing facilities as an important part of the health care system to improve the continuity and integrity of care. Skilled nursing facilities were designated to provide patients with medical, nursing, rehabilitation and palliative care, with the aim to care for patients discharged from hospitals with the goal of increasing the efficiency of health care system. In this document, measures such as incorporating the construction of skilled nursing facilities into regional health care planning, transforming existing hospitals into skilled nursing facilities, and encouraging the private sector participation were proposed. Similarly, the “Basic Standards for Rehabilitation Hospitals” was promulgated by the MOH in 2012 . In order to further encourage the private sector to establish community-based rehabilitation and nursing facilities, the “Basic Standards and Management Standards for Rehabilitation Medical Centers and Nursing Centers” was issued by the National Health and Family Planning Commission (NHFPC, renamed from MOH in 2013) in 2017 .
The integration of health and care was first proposed in a policy document to advance the development of elderly care in 2013, encouraging medical services to be provided in elderly care institutions, communities, and home-settings, and require medical institutions to provide better chronic disease prevention, rehabilitation, and nursing care for the elderly . In 2015, the integration of health and care was formally introduced as an independent policy. Nine departments, including the NHFPC and the MCA, jointly issued the “Guiding Opinions on Promoting the Integration of Health and Elderly Care Services”. This policy document defined the goal and proposed the main structure and supporting measures of integration. The basic goal was to set up a policy and regulation system and build a comprehensive and continuous integrated service network for the elderly in both urban and rural regions by 2020. The five forms of integration proposed included: cooperation between health institutions and social care institutions; provision of health care services in social care institutions; encouraging medical institutions to provide social care services; encouraging the private sector to set up institutions of integrated care; and the extension of health care services to communities and families. The first four forms are mainly care integration at the institutional level and the fifth is integration at the community level. Various supporting measures were proposed to support these integration efforts, such as investment and financing, regional planning, workforce development, IT system formation and inter-departmental collaboration.
To simplify and streamline administrative procedures for setting up new facilities providing integrated care, MCA and NHFPC jointly issued a policy to strengthen intersectoral cooperation to create a “barrier-free” environment for the registration of new institutions in 2016 . In 2017, the NHFPC canceled the administrative approval formerly required for establishing medical facilities within social care institutions, to be replaced by routine registration .
Care integration at the community level is facilitated by ongoing reform of strengthening of the primary health care system , in which the contracted services of family physicians were strongly promoted by the government. In a major policy document in 2016 , the government required residents to sign contracts with “family physician-led primary care teams” in community health institutions to receive a package of basic care including medical care, preventive care, and health management (including health assessment, rehabilitation guidance and home-based medical care, etc.). Primary care teams were led by family physicians or general practitioners with the support of nurses and public health professionals at community health centers, which are mostly set up and funded by local governments (municipalities or counties). The service packages provided varied across regions and would be adjusted over time, with cost shared by medical insurance, public health funds and the residents. Following this policy, the “family physician-led primary care teams” are accountable for residents’ overall health and wellbeing, including extending health care services to community care organizations and home-settings to support care integration at the community level.
Entering the 21st century, China has gradually established a basic social medical insurance system of universal coverage. By the end of 2019, 1.35 billion people in the country were enrolled in basic medical insurance schemes, with the insured rate stabilizing above 95% . The proportion of the elderly enrolled in social medical insurance schemes in urban and rural areas has reached 98.9% and 98.6%, respectively . Medical insurance covers health care only, while long-term social care is mainly financed by private payments supplemented by taxation and lottery funds .
By learning from the experiences of countries such as Germany, Japan, and South Korea, China began to explore a LTCI system after 2010. There were some local pilot programs aimed at establishing LTCI in the early 2010s. In 2015, “The 13th Five Year Plan for National Economic and Social Development” officially proposed to “explore building an LTCI system” by 2020. In June 2016, the LTCI demonstrations were launched by the Ministry of Human Resources and Social Security (MHRSS, the ministry in charge of social medical insurance at that time) . Fifteen cities across the country were selected as the first batch of national pilot cities. The goal was to explore a social insurance system that provides funds for “daily personal assistance and skilled nursing care in support of the activity of daily living” (a combination of health and care), mainly for long-term and severely disabled people.
Before 2018, the NHFPC was in charge of health care, the MCA was in charge of long-term social care, and the MHRSS and NHFPC were jointly in charge of social medical insurance. The policy of integration of health and care was mainly undertaken by the Family Development Department of the NHFPC in coordination with the MCA, while the management of LTCI was undertaken by the Social Insurance Department of the MHRSS. In the organizational reform of the State Council in 2018, the “Department of Elderly Health” was established for the first time by the NHC (renamed from NHFPC in this reform), integrating the former Office of Aging of the MCA, and was designated to coordinate health policies and develop a health care system for the elderly. Compared with the previous Department of Family Development, the “Department of Elderly Health” has a stronger position in policy coordination and resource integration . In the meantime, the National Healthcare Security Administration (NHSA) was established as an independent agency under the State Council, integrating the management of basic medical insurance schemes and LTCI, which laid an organizational basis for the policy and financial coordination of care integration.
By 2016, a total of 90 city districts/counties had been identified as national pilot sites for the integration of health and care [37, 38]. Different models of integration and implementation strategies have been demonstrated, including both institutional and community-based care.
By the end of 2019, a total of 56.4 thousand pairs of health institutions and social care institutions nationwide had signed cooperation agreements. There were 4,795 institutions qualified to provide both health and care, among which 3,172 were social care institutions that provided health care and 1,623 were health care institutions that provided social care . However, compared to the large quantity of institutions across the country (about 1 million health care institutions , 34.3 thousand residential social care institutions, and 64 thousand community social care facilities  in China in 2019), the number of institutions with both qualifications or providing integrated care remains a very small number.
The contracted service provided by family physician-led teams has advanced, and according to official data, 60% of older people across the country signed such contracts by 2017 . The contract, which is strongly pushed by the government, is more like a service agreement than a standard contract between the primary care teams and community residents, specifying the service contents and frequency. The home medical bed is a kind of home-based care providing medical and nursing care for those with chronic diseases and disability at home, and is one of the services in the family physician’s contracted service package under medical insurance hospital reimbursement. Shanghai is currently the city with the largest number of “home medical beds” in China. In 2019, there were approximately 72,000 home medical beds in Shanghai . A total of 95.75% of patients admitted are elderly people over 60 years old, and approximately half are over 80 years old. Most of the patients have some disabilities with diseases such as cardiovascular disease, stroke, chronic bronchitis, advanced tumors, and fractures. Service items include medical rounds, physical examination, basic nursing, rehabilitation, traditional Chinese medicine, medication, and palliative care . Health services have also been extended to cover the elders in community care facilities. These facilities are still in the initial development stage, providing mostly day care with some residential care. Integration of health care has been seen as a necessity by these facilities to align with policy directions and integration is carried out in various forms, such as setting up nursing stations inside , collaborating with hospitals, community health institutions, or even village doctors in rural areas [48, 49].
Despite the government’s intensions, the number of rehabilitation hospitals and skilled nursing facilities in China has grown at a very slow pace, with only 706 rehabilitation hospitals and 628 skilled nursing facilities across the country in 2019 (Table 2). It is argued that the medical insurance’s limited coverage of post-acute care is a main reason for the underdevelopment of aftercare facilities .
|REHABILITATION HOSPITALS||SKILLED NURSING FACILITIES|
The role of the private sector has been emphasized in this field, and the past decade has seen a surge of market forces in both institutional and community care. Over 70% of the rehabilitation hospitals are non-public and the ratio is 90% for skilled nursing facilities (Table 2), showing the increasing and dominant role of private sector in this field. Many insurance companies as well as real estate companies begun to operate businesses and build new facilities. Public-private partnerships (PPP) have also been widely adopted. According to the Ministry of Finance, 307 elderly care PPP projects were in progress in August 2017, of which 42.1% were projects integrating health care . There are also internet companies developing businesses in home nursing care or online family physician services, serving a complementary role for home-based care.
In 2016, 15 cities were designated as national demonstrations for LTCI schemes. LTCI coverage has expanded gradually and approximately 88.5 million people have participated in the pilot cities as of June 2019. Of them, 426 thousand participants (0.5% of the participants) were receiving LTCI benefits (Table 3) with an average benefit amount of about 9,200 RMB (1,193 EUR) a year . In 2020, the number of pilot cities was increased to 49 .
|PARTICIPANTS (MILLION)||PARTICIPANTS RECEIVING BENEFITS (THOUSAND)|
In the first 15 pioneer cities, the funding for LTCI comes from multiple sources, including the transferring of the surplus of basic medical insurance funds, collecting premiums from individuals and employers, government financial funds, and social endowments (such as welfare lottery funds). Eligibility for benefits has been established mainly for severe disability, with moderate disability and intellectual disability eligible in only a few cities. The benefits are provided mainly in the form of in-kind institutional and home care supplemented by cash allowance in several cities. Services covered include a spectrum of medical, nursing, and daily personal assistance [54, 55, 56]. With the different eligibility and reimbursement criteria in the 15 pilot cities, it was estimated that the proportion of LTCI spending would range from 0.08% to 1.90% of GDP for China in 2015, and this proportion will increase to 0.28% and 5.90% respectively in 2055 as the aged population continues increasing . Therefore, the eligibility criteria and reimbursement rate should be deliberately designed and calculated to ensure the financial sustainability.
With LTCI, a stable source of funds is provided for long-term care and related health care, which stimulates service supply, relieves pressure and reduces the financial costs of medical care . For example, as one of the first cities to establish LTCI, the number of skilled nursing facilities in Qingdao City of Shandong Province has increased greatly. By the end of 2018, there were a total of 107 nursing facilities providing institutional care, and more than 600 institutions providing home care in Qingdao . The per diem cost for LTCI beneficiaries is 10–20% of the cost of those with similar conditions covered by medical insurance in 2012 in Qingdao, reflecting significant cost savings for both families and government .
In addition to current national LTCI demonstrations in 49 cities, new LTCI models are also being developed by commercial insurance companies. According to an investigation, 6 insurance companies in China conducted LTCI business in 2014, with 55 products on sale . However, the scale of commercial LTCI is very small, accounting for less than 3% of the commercial health insurance (544.8 billion RMB or 70.8 billion EUR) in 2018 .
China has come to recognize that the traditional separate model of health and care cannot meet the needs of the elderly in its advancing aging process. There are three approaches China takes in promoting health and care integration:
In spite of progress made, China is still in the early stage of integrating health and care. In general, there are some challenges with regard to financing, management, and administration at the system level, and issues such as a shortage of professionals, a skilled workforce and a lack of assessment tools and quality standards.
Since there is much that needs improvement in China’s current health and care system, promoting the integration of health and care is an arduous task. However, China has realized the importance of integration and has identified it as a priority at the policy level. With these policies, the continuous integration and improvement of care will dominate the future development of the aged care system. In the future, the following considerations should be taken to further promote the integration of health and care.
With much accomplished, China still has a long way to go in the integration of health and care. The Chinese government has formulated and implemented its policies by mobilizing local governments and the private sector through a top-down approach and national demonstrations. Since 2010, a significant amount of work has been done, such as integrated care models implemented both at the institutional and community level and financing mechanism of LTCI established in addition to the existing medical insurance scheme. However, the top-level design of the system, as well as some specific models, tools, and standards still need to be improved or established, and the capacity of both health and care systems need to be enhanced. It is anticipated that China will make further progress in the field with the strong adaptive and administrative capacity of the government and an actively participating society and market.
LTCI, long-term care insurance
MCA, Ministry of Civil Affairs
NHC, National Health Commission
MOH, Ministry of Health
NHFPC, National Health and Family Planning Commission
MHRSS, the Ministry of Human Resources and Social Security
NHSA, National Healthcare Security Administration
This research is supported by the Key Project of National Nature Science Foundation of China (72034005) and Fundamental Research Funds for the Central Universities of China (3332020068).
K. Viktoria Stein, Department of Public Health and Primary Care, Leiden University Medical Centre, The Netherlands.
Yue Qiu, Ph.D, Director of Research Department of China Development Research Foundation, Research fellow of Development Research Center of the State Council, China.
The authors have no competing interests to declare.
LH and YWG jointly designed the structure and content of the paper. RY, CP, MY and YZ did literature review and data collection. LH was the major contributor in preparing the manuscript. YWG reviewed multiple drafts, provided guidance and revised the final manuscript. YL provided guidance and overall support for the paper. All authors read and approved the final manuscript.
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