Zhang Shiping, Deputy Director of the Organizing Committee of the Healthy China 50 Forum, former Vice Chairman of the All-China Federation of Trade Unions, and Deputy Director of the Social and Legal Committee of the 12th National Committee of the Chinese People's Political Consultative Conference. This is her speech at the annual meeting of the Healthy China 50 Forum (held in Tongling, Anhui Province on April 14, 2024).
The author is from the All-China Federation of Trade Unions, has worked in the All-China Women's Federation for 30 years, worked in the Federation of Trade Unions for more than 10 years, and has been involved in and promoting the cause of health after coming down from the second line. He also submitted a number of special proposals involving pension issues to the National Committee of the Chinese People's Political Consultative Conference, and made a speech at the National Committee of the Chinese People's Political Consultative Conference on actively responding to the aging of the population, and clearly put forward that the active response to the aging of the population should be the basic national policy. Since 2019, relying on the China Health Management Association, with the support of 8 ministries and commissions including the National Health Commission, three health promotion projects have been launched, one of which is the National Health Promotion Project for the Elderly, which has clarified the focus of promoting the three-level medical care model and one-stop service for health tourism, and established the construction goals of 6 major service systems such as smart and healthy life services for the elderly at home, and many tasks are currently being promoted.
The following is the main text:
This year, the two sessions once again clearly proposed to implement a national strategy to actively respond to the aging of the population. This annual meeting focuses on social security for the elderly, reflecting the conscious implementation of the spirit of the two sessions. I would like to take this opportunity to talk about my thoughts on the issue of healthy elderly care.
The mainland is a developing country with the most severe population aging. Compared with other countries, the mainland's population aging characteristics are distinct: first, the base is large, fast growth, now accounts for 21.1% of the national population, close to 300 million, and at an annual rate of more than 10 million, in 2050 will exceed 500 million, accounting for about 37.8% of the population, significantly higher than the world average growth value. Second, the trend of aging is obvious, with about 80 million elderly people, and it is expected that there will be more than 150 million people over 80 years old in 2050. Third, the number of empty nesters living alone has increased, and family planning has accumulated 180 million families, and there are currently more than 90 million empty nest elderly people living alone, accounting for about 1/3 of the elderly population. In 2022, the social dependency ratio in mainland China is 21.8%, and it is expected to rise to 40%-50% from 2030 to 2050, and every 2-3 young people will have to support 1 old man. Fifth, there are obvious differences between regions and urban and rural areas, with the eastern region aging significantly faster than the western region, and the rural population aging surpassing that of the cities, which is related to the population structure, fertility policy and economic development level. Sixth, the health status is worrying, the vast majority of the elderly are in a sub-health state, 75% of the elderly suffer from one or more chronic diseases, and about 45 million elderly people are disabled and demented. In 2001, when the mainland entered the aging population, the per capita GDP was only 4,000 US dollars, lower than the international average of 5,000-10,000, and has now entered a moderate aging, and the per capita GDP is far lower than the average level of developed countries. Eighth, developed countries generally start to prepare at least 30 years in advance, such as Australia in the 90s of the last century to deal with the peak of aging in 2030, we have a large population, thin foundation, the response to aging, understanding and starting are relatively late. The above eight characteristics are the basic national conditions that we cannot avoid and must face.
Healthy pension is the common pursuit of the people, and it is also an important symbol of national civilization and progress and the basic requirement of social harmony and stability. It refers to providing comprehensive physical health, mental health and social participation services for the elderly, so that they can maintain their health, delay aging, and achieve the goals of safe care, happy living and good death. How to promote healthy old-age care? According to the basic national conditions and the needs of the elderly, there are four major problems that need to be solved urgently, namely: Where does the money come from? Where do the people go? Who will do the living? Who will take care of the health? These difficult problems need to arouse our great attention and take effective measures to promote the solution.
First, the first difficult problem is where the money will come from? The question is the basic livelihood security and medical security for the elderly.
At the end of 2022, the average pension in mainland China was about 3,000 yuan, of which about 70% were less than 3,000 yuan and about 3% were more than 10,000 yuan. Pension can only maintain the general family, once there is a serious illness or the elderly are disabled and demented, this money is simply not enough, some even hourly workers can not afford to pay, let alone bear the high cost of nursing homes, can only rely on children at home to take care of.
The elderly in rural areas mainly rely on land for food and medical and pension subsidies of less than 1,000 yuan to survive. Now there are more and more landless farmers, it is expected that in 2027, the 30-year contract expires, the landless farmers will reach 260 million, the space for eating on the land is getting smaller and smaller, and the support of children and their own labor income is now the main source of livelihood for the elderly in rural areas.
The state has made great efforts to promote urban and rural medical and social security, and has taken three-pillar development measures, but the current pension system still has problems such as insufficient total assets, structural imbalance, and prominent contradiction between supply and demand, and it is predicted that in the next 5 to 10 years, there will be a gap of 8 to 10 trillion pensions in the mainland, and the gap will continue to expand over time. Long-term care insurance for the disabled and disabled and dementia elderly has been called for many years, and has been piloted in more than 40 cities, and the elderly care institutions and homebound elderly in the pilot areas have benefited, but for the 45 million disabled and dementia elderly, it is still a drop in the bucket and it is difficult to achieve full coverage.
As an important supplement to old-age security, commercial insurance has developed greatly in recent years, and the Insurance Regulatory Commission has also carried out exclusive old-age commercial insurance pilots in some provinces and cities, expanded the insured objects, and explored a variety of payment methods. But on the whole, our commercial insurance is still very immature, the product homogeneity is serious, the innovation is insufficient, and some insurance companies are biased towards the healthy, and the insurance objects are very limited. Older people rely too much on the first pillar, have no awareness of commercial insurance, and lack trust, and have only a limited number of people who can benefit from it.
How to solve the problem of where does the money come from?
First, it is necessary to deal with the problem at the source, implement the birth policy, promote population growth, curb the development trend of more insurance recipients than payers caused by the declining birthrate, and strive to reduce the risk of the social insurance fund exceeding its income and expenditure.
Second, it is necessary to open up sources and reduce expenditure, focus on solving supply-side problems, and strive to maximize the benefits of pension funds. It is necessary to further intensify the medical reform, effectively solve the problems of shifting the center of gravity downward, integrating China and the West, and using medicine to support medicine, especially to take effective measures to solve the huge problem of waste of medical expenses, deepen the reform of payment methods, and effectively improve the efficiency of the use of medical insurance funds.
Third, it is necessary to give full play to the leading role of the government, further improve the basic pension system, adhere to fairness and justice, implement the full payment, ensure the supporting role of the first pillar, and promote its stability and sustainable development, especially to fully establish and implement the long-term care insurance system as soon as possible, so that more elderly and disabled and dementia elderly people can benefit from it.
Fourth, it is necessary to optimize the multi-pillar pension security system, promote the full development of the second and third pillars, enrich the pension tools, disperse the pension risk, expand the coverage of enterprise annuity and occupational annuity, develop various commercial pension and health insurance for the elderly, increase support for the product development of insurance companies, promote the construction of standardization, and promote the integrated development of the three pillars.
Second, the second difficult question is where do people go? The question is the issue of ensuring a place for the elderly to live in peace.
The mainland pension is a 9073 structure, and among the 280 million elderly people, 90% are home-based pensioners, to be precise, the family is naturally old-aged, and the families who can access community door-to-door services are very limited. Among the elderly at home, there are 180 million young and energetic elderly people, who are currently able to stand on their own, but their lives are under great pressure, especially the generation born in the fifties and sixties, who bear the family responsibility of taking care of their parents and helping their children, and they simply cannot leave their homes, and there are many limitations in sending their parents to nursing homes.
Community care mainly refers to day care centers, which can provide daycare and family emergency services, but cannot solve the problem of elderly care. Most of the 41,000 registered pension institutions are managed by the civil affairs system and have financial subsidies, while urban institutions are hard to find a bed, rural institutions are deserted, and facilities and sanitation conditions are relatively poor. Most of the elderly in rural areas have to take care of left-behind children, and few of them are able to go to nursing homes. Private nursing homes have developed greatly in recent years, but some of them are too expensive for ordinary families to bear; some of them suffer serious losses and are unsustainable, especially for private non-elderly care institutions, where there are too many policy bottlenecks.
By the end of 2023, there were 8.201 million elderly care beds in the country, down from all in 2022. 1/3 of them are day care centers, and there are only more than 5 million beds for the elderly, not to mention the elderly, and only 12% of the 45 million disabled and dementia elderly can be accommodated, which is only a fraction. It is conceivable that now 180 million young and energetic elderly people are basically at home, and in 10 or 20 years? They are all only children, who will support them? At that time, the demand for old-age care institutions must have erupted, and the existing more than 8 million beds are simply not enough. Some comrades said that the vacancy rate of old-age beds is too high at present, and it is necessary to control development. I think this statement is both inaccurate and short-sighted. We must see that the structural contradictions are prominent, most of the vacant ones are low-quality nursing homes in rural areas, and really good nursing homes are still very scarce. The construction of pension institutions should not only be based on the present, but also focus on the long-term, and must not be relaxed, in fact, it is relatively late to start now.
How to solve the problem of where people go?
First, we should rely on the community and vigorously develop home-based elderly care. Home care is essentially a combination of family care and social care, based on the family, relying on the society, to provide professional and all-round care services. This model, which is well established in developed countries and is just beginning in our country, should be the focus of development. The "14th Five-Year Plan" clearly proposes to develop inclusive elderly care services, build a coordinated elderly care model between home and community, realize full coverage of elderly care service facilities in all urban areas and communities, and create a quarter-hour home care service circle. There is a long way to go to achieve this goal, and it is not enough to rely on government investment alone, and it is necessary to mobilize social resources to form an overall joint force. In accordance with the principles of openness, equality and standardization, the government should lower the threshold for participating in community pension services, implement support policies such as taxation, finance, water and electricity, and purchase of services, cultivate leading enterprises in community pension services, develop door-to-door services and online services, and build a brand of home-based community pension services.
The second is to actively promote the construction of old-age institutions, especially to fully develop community resources, and vigorously develop small community nursing homes and nursing homes that are adjacent to the community, combined with medical care and elderly care, multi-driven, mutually helpful, convenient for children to visit and have preferential prices, and provide a place for the elderly to recuperate nearby, so as to reduce the burden of family support for the young elderly. The state proposes that by 2025, the number of elderly care institutions in the country will reach 100,000 and the number of beds will reach 12 million, hoping that this goal can be achieved as scheduled. In fact, it is impossible to provide for the elderly in a health care base far away from home, with mountains and rivers, and it can only be a place for young and energetic elderly people to live in health care, and no one can send their parents who are eighty or ninety years old to live in Wudalianchi and Xishuangbanna. We must make the concept of pension and health care clear.
Third, it is necessary to strengthen the policy support for the existing pension institutions, especially private and non-governmental institutions, and urge them to improve facilities, enrich content, improve services, update and iterate, and achieve sustainable development. At the same time, special attention should be paid to the development and construction of rural pension service facilities and quality upgrading, starting from the actual needs of the elderly in rural areas, the development of service projects, improve the living environment, improve the quality of service and nursing level, and solve the problem of high vacancy rate in rural nursing homes, especially for the development of a number of door-to-door pension services for the elderly left behind in rural areas.
Fourth, it is necessary to strengthen the family social responsibility of respecting and helping the elderly, consolidate and develop the family pension with the traditional foundation of the Chinese nation, introduce preferential policies such as taxation to support family members to live with the elderly or live close to the neighbors, and fulfill the obligation to support the elderly in accordance with the law, promote the mutual aid and mutual aid model of family members and the elderly, advocate the "old partner plan" with mutual assistance, companionship, and group pension as the core, and support a variety of pension models such as comrades-in-arms, relatives and friends, neighbors, interest groups, and migratory bird groups.
Third, the third difficult problem, who will do the living? It is about the issue of ensuring the availability of personnel for elderly care services.
At present, the care of the elderly and the disabled and dementia at home basically depends on their children, and most of these children are young and elderly. There is a report about a 67-year-old man holding a small spoon and bending over to feed his 83-year-old father lying on the bed one bite at a time, and the sun shines on his gray hair, which is very touching and sentimental. In fact, this situation abounds all around us, and the phenomenon of "caring for the elderly" is very common. Especially taking care of the elderly with dementia and disorders, the family often makes a mess.
At present, most of the people engaged in nursing services are 40 or 50 laid-off workers and female migrant workers, who do not have high cultural quality, lack professional skills, and poor job stability. Affected by the epidemic, the phenomenon of labor shortage and staff loss in pension service institutions has become more and more prominent.
There is a great mismatch between the structure of nursing staff and the care needs of the elderly, 45 million disabled and dementia elderly people need nursing, if calculated according to the ratio of 1:4, more than 11 million nursing positions are needed, less than 500,000 nursing staff in existing institutions, and less than 100,000 people are certified to work. Nearly 100 vocational colleges across the country have opened geriatric service majors, but most of the students will not go to the front-line positions of geriatric care after graduation. Pre-job training is also a big gap, and a complete training mechanism and work system have not been formed. Due to factors such as social cognition, salary level, and work intensity, there have always been problems such as low academic qualifications, insufficient skills, difficulty in recruiting and retaining people, and some young people use pension institutions as a temporary springboard.
The position of elderly care worker is very demanding, not only to be caring, patient, careful, but also to bear a lot of psychological pressure, not only to have medical treatment, rehabilitation, life care and other aspects of knowledge, but also to have the ability to deal with emergencies. The quality and ability of nursing staff have a great impact on the quality of life and life expectancy of the elderly, especially the disabled and dementia elderly to achieve a quality and dignified life, which is inseparable from the meticulous and high-quality care of nursing staff. Solving the problem of the source and quality of nursing staff is an important bottleneck and huge demand for the development of healthy elderly care.
How to solve the problem of who will do the work?
First, it is necessary to strengthen the construction of the team of elderly care professionals, support institutions of higher learning and vocational schools to increase the number of professional courses for elderly care services, cultivate professionals in geriatric medicine, health management, nursing, etc., and strive to do a good job in the professional design and teaching layout of five teachers, including geriatric nurses, rehabilitation therapists, health managers, psychological counselors, and nutrition instructors, and incorporate them into an important series of national higher vocational education development.
Second, it is necessary to support the development of school-enterprise cooperation and targeted training of pension professionals. At present, the state has issued a professional catalogue and professional standards for elderly care workers, and the key is how to effectively implement them in the construction of occupations. Relying on pension institutions and various training resources, various forms of on-the-job education and on-the-job training should be carried out, and a training base for pension services should be established, so as to strengthen the pension service team and improve its professional and standardized level.
Third, it is necessary to implement preferential policies and reward mechanisms for elderly care talents, care about their career development and interests, improve the rating of professional titles, straighten out the upward channels, give them more understanding, fairness and respect, and attract more young people to join the ranks of elderly care services through the improvement of welfare benefits, the improvement of social recognition, and the enhancement of professional belonging.
Fourth, it is necessary to strengthen social and cultural construction, enhance the function of social self-help and mutual assistance, advocate the elderly to do something and volunteer service for the elderly, mobilize the majority of young people, young people and all walks of life to join the ranks of volunteers, and pension institutions, the elderly at home to pair up to help, promote the successful experience of time banks and service banks, and provide life care, legal help, spiritual comfort, cultural entertainment and other services for the elderly, which not only advocates the new style of loving the elderly and helping the elderly, but also supplements the needs of old-age services.
Fifth, it is necessary to vigorously develop smart pension, build a network platform for home-based elderly care services, support pension enterprises and institutions to use the Internet, Internet of Things, big data, artificial intelligence and other technical means to empower pension services, and promote floor monitoring, smart alarm, housekeeping appointment, intelligent bathing, health consultation, item purchasing and other technical services, improve service efficiency, reduce labor costs, and let digital technology resonate with the elderly society at the same frequency.
Fourth, the fourth difficult problem, who will take care of health? The issue of ensuring health services for the elderly is discussed.
Now the elderly live longer, eat well, have more chronic diseases, and have common health problems. The four chronic diseases of cardiovascular and cerebrovascular diseases, diabetes, respiratory diseases, and cancer defined by the World Health Organization, as well as the four new chronic diseases of psychological and nervous system diseases, bone and joint and trivertebral diseases, eye diseases, and oral diseases, are all reflected to varying degrees in the elderly, and the phenomenon of old age and multiple diseases is very common.
In fact, many chronic diseases can be intervened early, moderately regulated, and prevented before they occur. For example, the formation of cardiovascular and cerebrovascular diseases is mainly caused by cold and dampness, congestion, blood obstruction, and nodules, and the daily maintenance and conditioning of blood, airway, and intestine is very important, and it is also closely related to diet and exercise. Another example is Alzheimer's disease, with more than 10 million people suffering from it in China, ranking first in the world. This is a neurodegenerative disease, which usually has symptoms such as memory loss, mental retardation, personality changes, and decreased life ability in the early stage, which should also be detected and intervened in time. According to the survey, the proportion of patients with this disease is relatively high in rural areas, relatively lower in urban areas, and the higher the education level and the more brain use, the lower the probability of suffering from this disease. This shows that the more you use your brain, the more you use it, the more you use it.
After the epidemic, people's health needs are becoming more and more intense, but what is health and how to achieve health? Many people are not very clear, and over-reliance on hospital doctors is still common. In particular, the medical expenses of the elderly remain high, which has not only become a pressure on medical insurance, but also a heavy burden on families. There is a lack of health service management system in the mainland, and the elderly have limited access to health knowledge and health services. In the society, all kinds of health care products are mixed, and it is not uncommon to be deceived. There are also unhealthy lifestyles, eating habits and environmental factors, which greatly affect the health of the elderly.
How to solve the problem of who is in charge of health?
First, the focus should be shifted downward to promote the construction of a pension service system that combines medical care and elderly care. This is a new type of old-age care model that combines disease treatment, disease-free recuperation, and health care, and creates a closed-loop service chain that combines prevention, treatment, rehabilitation, nursing and life care. Whether it is a pension community or an elderly care institution, it should adhere to the development direction of the combination of medical care and elderly care, and rely on local medical institutions to provide convenient medical security and general practitioner services for the elderly. In this regard, we are not as good as developed countries, and medical resources are often the most scarce at the grassroots level, especially in rural areas. The Government should make great efforts to address this issue.
Second, based on the community, vigorously develop health management, actively develop community service facilities that integrate health care and medical care, fully tap the surrounding idle sites, institutions, real estate, primary and secondary hospitals and other resources, promote the construction of health stations and rehabilitation centers for the elderly in the community, and form a consortium with local nursing homes and nursing homes, which not only supplement the lack of nursing care for the elderly, but also provide chronic disease management, traditional Chinese medicine conditioning, rehabilitation treatment and other services for the elderly.
Third, it is necessary to pool resources, actively promote the construction of health and cultural tourism bases featuring rehabilitation, and provide rehabilitation, recuperation, and sojourn services for the young, young and energetic elderly. In the past, rehabilitation was mostly limited to postoperative rehabilitation and disability rehabilitation, and it was difficult to find a single bed in the hospital's rehabilitation center, and there were only more than 100 specialized rehabilitation hospitals. In fact, people with chronic diseases, especially the elderly, need rehabilitation, but there is no awareness and channels in this regard. It is necessary to make full use of the resources of cultural tourism cities, real estate, hot spring hotels and other resources in various places, and vigorously develop rehabilitation homes, sanatoriums and health management homes to meet the diverse needs of the elderly for health recuperation, spiritual culture and so on.
Fourth, it is necessary to support the development of traditional Chinese medicine products, medicine and food homologous products, nutritional products and various products and equipment suitable for the elderly according to local conditions. Chinese patent medicine has a special effect on chronic diseases, but the type and quality are limited, and the export share of Chinese herbal medicine raw materials in the mainland accounts for 85%, while the export of Chinese patent medicine is less than 2.5%, indicating that there is huge room for development. There is a great demand for products such as medicine and food homology and cytonutrients, and the key is to have standards, quality and supervision in place. Foreign rehabilitation equipment and products for the elderly are widely used, and there are few types of rehabilitation equipment in the mainland, most of which rely on imports, so we should increase development efforts and develop national brands.
Fifth, it is necessary to face the society, widely publicize the concept of healthy old-age care, vigorously strengthen the health education of the elderly, actively implement the health promotion project for the elderly, promote a civilized, healthy and scientific lifestyle, develop sports projects suitable for the characteristics of the elderly, pay attention to the mental health of the elderly, and advocate a lifelong self-reliance, active health, and active participation in the social culture of the elderly. Who is in charge of health? More importantly, we must rely on ourselves, the best doctor is ourselves, the best hospital is the kitchen, and the best medicine is diet. Everyone should be the first person responsible for their own health, and I am the master of my health. It is necessary to guide the elderly to strive to practice 5 words and 20 words, namely: happy mood, reasonable diet, scientific exercise, moderate conditioning, and participation in society, and if you practice these 5 points, you can move towards the goal of ensuring 100 years old and sprinting to 120, and achieve quality, value and dignity.
To solve the above four problems, we must be led by the government, participated by the society, and mobilized by the whole people, so as to create a working situation in which the whole society works together, works together, and builds and shares. At the same time, it is also necessary to comprehensively and accurately grasp the orientation of the old-age work, and clearly understand: the problem of aging is not a local problem, but an overall strategic problem; it is not a phased problem, but a long-term problem with a certain historical development stage; the elderly are not a burden of society, but the wealth of society; the goal of coping with the aging of the population is healthy aging and active aging, not passive old-age care, but actively enjoying the old-age; the work of the elderly cannot be simply engaged, but should be divided into ages, needs, In the work for the elderly, we must carry out top-level design in the spirit of reform, open thinking, and innovative measures, learn from advanced foreign experience, proceed from our national conditions, strive to achieve overtaking in corners, and actively build a long-lasting and powerful country.
