Towards aging-in-place: collaborative governance in senior health and care system

National Interdisciplinary Institute on Aging (NIIA) ,Southwest Jiaotong University, China

Ⅰ The problem

Unhealthy aging and mismatch between supply and demand

The demand side

20002002

20042006

20082010

20122014

0

20

40

60

80

100

120

140

160

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Population aged over 65 in China (2000-2014)

population aged over 65 (million)percentage (%)

2015 2020 2025 2030 2035 2040 2045 20500

50

100

150

200

250

300

350

400

450

500

152

193226

269

334

382400

430

Population aged over 65 in China (2015-2050)

population aged over 65 (million)

*Data from China's National Bureau of Statistics *Data from United Nations Population Division

Life expectancy at birth in China (years)

Year 1990-1995 2005-2010 2010-2015 2015-2020 2025-2030 2045-2050

Life expectancy 69.4 74.4 75.4 76.5 78.6 82.5

Data from United Nations Population Division

2012 2013 2014E 2015E34

35

36

37

38

39

40

41

36

37

39

40

The number of disabled/semi-disabled elderly in China

The number of disabled/semi-disabled elderly(million)

*Data from China Research Center on Aging

2015 2020 2025 2030 2035 2040 2045 20500

5

10

15

20

25

30

35

14.04

16.38

19.15

23.12

26.32 27.228.15

29.86

4.89 5.716.68

8.069.18 9.48 9.81 10.41

1.63 1.9 2.23 2.69 3.06 3.16 3.27 3.47

The number of beds and paramedics required for fully disabled elderly (2015-2050)

Number of fully disabled elderly(million) Number of beds required(million)Number of paramedics required(million)

*Data from China Research Center on Aging

0-4 5-14 15-24

25-34

35-44

45-54

55-64

over 65

0

10

20

30

40

50

60

0 0 1.443.83

11.5

23.54

38.9

53.99

The prevalence of chronic diseases in survey areas in 2013

prevalence rate of chronic diseases(%)

*Data from China health statistics yearbook (2015)

Chronic diseases Prevalence(%)

Hypertension 19.72

Cerebrovascular 3.85

Diabetes 3.68

Chronic obstructive pulmonary disease

3.42

Arthritis deformans 3.07

Ischemic heart disease 3.05

Gastroenteritis 1.95

Intervertebral disc disease

1.94

Gallstones and cholecystitis

1.09

Cataract 0.86

Top 10 chronic diseases of the elderly

*Data from China Report of the Development on Siliver Industry (2014)

The supply side

Germany

Australia

France

United Kingdom

United St

ates

CanadaKorea

ChinaIndia

0

0.5

1

1.5

2

2.5

3

3.5

4

4.54.05

3.39 3.33

2.772.56 2.55

2.17

1.65

0.73

The number of physicians per thousand people in selected

countries in 2013

The number of physicians per thousand people

JapanKorea

Germany

France

Switz

erland

China

United Kingdom

Sweden

India0

2

4

6

8

10

12

14 13.32

10.96

8.28

6.29

4.68

3.32.76 2.59

0.5

The number of beds per thousand people in selected

countries in 2013

The number of beds per thousand people

*Data from OECD

34%

48%

17%

1%

The downsizing family

one-generation householdstwo-generation householdsthree-generation householdsfour-generation households

1953 1964 1982 1987 1990 1995 2000 2005 2010 20150

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

4.33 4.43 4.44.2

3.963.7

3.44

3.13 3.1 3.02

Average number of residents per household

Average Number of Residents per Household ( person)

*Data from China's National Bureau of Statistics

50-54 55-59 60-64 65+0

5

10

15

20

25

30

35

40

45

50

44.1

39.537.6

36.2

The rate of empty nest elders

The rate of empty nest elders(%)

*Data from China family development report (2015)

1953 1964 1982 1987 1990 1995 2000 2005 20100

2

4

6

8

10

12

14

7.4

6.5

8 8.3 8.3

9.29.9

10.7

11.9

The elderly dependency ratio in China (1953-2010)

The elderly dependency ratio (%)

*Data from China Statistical Yearbook (2011)

Rapid growth of the elderly population

Institutional care• Not enough supply

Family care• Weakening

Tremendous demand on health care

Insufficient supply

Transmission

The extension of life expectancy

Higher prevalence rate of chronic diseases

Ⅱ Challenges

Insufficiency, mismatching and misallocation of medical resources;Difficulty in integrating both medical and nursing service

1993 1998 2003 2008 20130

5

10

15

20

25

3.6 3.5 3.6

6.8

9

6.1

8 8.4

15.3

19.9

Hospitalization rate in survey areas (1993-2013)

Hospitalization Rate (%)

Hospitalization Rate of 65 and over(%)

2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

1

2

3

4

5

6

The number of beds per thou-sand people have in all kinds of medical and health institutions

in China(2005-2014)

The number of beds per thousand people

The number hasn’t changed much in recent 10 years.

*Data from China health statistics yearbook

2009 2010 2011 2012 2013 20140

1

2

3

4

5

6

7

2.66

3.153.53

4.17

4.94

5.78

The number of beds in all kinds of care institutions in China

(2009-2014)

The number of beds in all kinds of pension institutions(million)

*Data from Statistical bulletin of the development of social services

2009 2010 2011 2012 2013 20140

10

20

30

40

50

60

70

80

9079 77

7470

6255

Actual occupancy rate of pen-sion institutions in China(2009-

2014)

Actual occupancy rate of pension institutions(%)

The actual occupancy rate of care institutions has been decreasing.

Total

Total a

ssets

Health te

chnicia

ns

Building a

rea

Equipmen

t over

¥10,000Bed

s0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

2.6%

80.9%

62.5% 59.6%

84.7%

75.2%

3.5% 2.6% 5.5% 4.6% 1.8% 3.0%

Hospitals Community health centers

Allocation of resources between hospitals and community health centers

*Data from China health statistics yearbook 2015

*Data from China health statistics yearbook 2015

Hospitals (2.6%)

Community health centers (3.5%)

total assets 80.9% 2.6%

health technicians 62.5% 5.5%

building area 59.6% 4.6%

equipment over ¥10,000 84.7% 1.8%

beds 75.2% 3.0%

bed usage rate 88.0% 55.0%

average days of hospitalization 9.6 9.6

annual visits 39.1% 9.0%

check-up 41.2% 14.4%

visits per physician receives daily 7.5 15.7

Input

output

More high-quality

resources

Attracting more patients

More income and grant

Hospitals

Lack of resources

Lack of high-level personnelLess patients

Less income

Community health centers

• Medical insurance can only be reimbursed in designated medical institutions (hospitals).

• The reimbursement ratio can be much higher if patients choose to be hospitalized; And within specified scope, the higher hospitalization expenses, the higher the reimbursement ratio is

High-level medical service

High-level care facilities

hospital-based health care

general care facilities

Community health service

Community-based nursing homes

Self-supportFamily support

Community support

Actual structure

shrinking

gatekeeper in healthcare, accessible but too weak

Need to be rebuilt

professional but too crowded

Three lacks of current system

Accessibility fairness

efficiency

Ⅲ The Aim

From “9073” towards Aging-in-place

90%

7%

3%

90% live at existing home with assistance of service and care

3% live in nursing homes or care facilities

7% get community care service, such as community based nursing homes

PREVIOUS Aim: the “9073” system

97% of the senior will realize “ageing in place”

High-level medical service

High-level care facilities

hospital-based health care

general care facilities

Community health service

Community support

Community-based nursing homes

Self-support Family support

AGING IN PLACE with services

Medical-nursing combined care

• Medical institutions were not approved to establish pension institutions, and vice versa.

(The State Council issued a circular on April 9th this year approving the above-mentioned activities)

Remaining problems: Finance, price, reimbursement……

geriatrics

rehabilitation nursing medical service

rehabilitation nursing

Ⅳ The Path

collaborate to build a senior health and care system response to “aging in place”

High-level medical service

High-level care facilities

hospital-based health care

general care facilities

Community health service

Community support

Community-based nursing homes

Self-support Family support

The elderly

Market

Social organizations

Community

Family

Health sector(government)

Incentives of the government

• To respond to the reform of downsizing and decentralization • Unable to meet the elderly’s increasingly diverse and complex

need all by itself; lack of professionality in service delivery

Incentives of social organizations

• As social forces grow, civil society wants to be involved in public affairs

• To get support from the government• To enhance its strength by the inflow of resources

Government

governor

implement medical reformcoordinate the market, community and social organizations and pool resources introduce preferential policies

supervision and evaluation

buyer improve the mechanism of service outsourcing

Social organization,market

provide formal health care service

Family provide informal care、 purchase formal careThe elderly self-help, mutual aid, offer feedback

Different roles of subjects involved in collaborative governance

Market

Government

Social organizations

Community

Family

guidancestaff

fundsguidance

purchasepolicies

purchase

High-level medical service

High-level care facilities

hospital-based health care

general care facilities

Community health service

Community support

Community-based nursing homes

Self-support Family support

The elderly

Market Government

Social organizations

Community

Family

purchaseguidance

staff

fundsguidance

purchase

policies

Health sector

Policy implications

• Implement the word of “aging-in-place” to replace “family/community”.• Socialization means that more social and market-driven resources to be

introduced, which should be ehanced.• Collaborative governance is the most possible way for China to solve the

problem of increasing need of health and care for elderly. • Care-giver-support system is needed!

Thank you