Asian Bioethics Review

, Volume 11, Issue 1, pp 57–68 | Cite as

Access to Care by Older Rural People in a Post-Reform Chinese Hospital: an Ethical Evaluation of Anthropological Findings

  • Xiang ZouEmail author
  • Jing-Bao Nie
Original Paper


This paper examines older people’s access to care experiences in rural China by integrating anthropological investigation with ethical inquiry. Six months of fieldwork in a post-reform primary hospital show how rural residents struggle to access gerontological and nursing care under socially disadvantageous conditions. This anthropological investigation highlights the unmet needs in medical and nursing care for older people, as well as some social, institutional and structural elements that impede access to care. Centring on protecting the vulnerable as informed by feminist ethics scholarship, this paper argues that the failure to meet older people’s dependency needs is unjust, on the premise that it suggests a denial of the inherent value, rights and dignity of older people. This paper appeals for the provision of greater care and support by the state through putting in place social arrangements that better advance older people’s access to care. Some policy recommendations concerning health and social care reform for older people in rural China are also proposed.


Access to care Gerontology Ageing Aged care Healthcare reform Rural healthcare China 


Compliance with Ethical Standards

The Human Ethics Committee of the University of Otago in New Zealand approved the research (Reference No. 15/106).

Informed Consent

All participants involved in this study have given their informed consent in oral form, as participants might have been reluctant to express their experiences and perspectives if they would have been required to sign a written consent form, especially with the research involving personal information. On the one hand, signing a document is a quite serious undertaking in a Chinese cultural context, and on the other hand, oral consent is generally honoured and accepted in Chinese society. Therefore, taking consent orally was helpful in minimising the participants’ fear of identification and establishing their trust in the researcher. Additionally, written consent was impractical given that many of the participants were illiterate.

To protect the confidentiality and privacy of the research participants, all identifying information was removed. For example, the names used in this paper—including those of informants and locations—are pseudonyms.


  1. Baker, John. 1992. Arguing for equality. London: Verso.Google Scholar
  2. Baier, Annette. 1994. Moral prejudices: Essays on ethics. Cambridge MA: Harvard University Press.Google Scholar
  3. Barber, Sarah L. and Lan Yao. 2010. Health Insurance Systems in China: A brief note. World health report 2010, background paper 37. World Health Organization. Accessed 13 March 2019.
  4. Bloom, Gerald. 2011. Building institutions for an effective health system: Lessons from China’s experience with rural health reform. Social Science & Medicine 72 (8): 1302–1309. Scholar
  5. Chan, Kam Wng, and Li Zhang. 1999. The hukou system and rural-urban migration in China: Processes and changes. China Quarterly 160: 818–855. Scholar
  6. Croll, Elisabeth J. 1999. Social welfare reform: Trends and tensions. The China Quarterly 159: 684–699.CrossRefGoogle Scholar
  7. Dodds, Susan. 2014. Dependence, care, and vulnerability. In Vulnerability: New essays in ethics and feminist philosophy, ed. Catriona Mackenzie, Wendy Rogers, and Susan Dodds, 181–203. New York NY: Oxford University Press.Google Scholar
  8. Eichner, Maxine. 2010. The Supportive State: Families, Government, and America's Political Ideals. New York, NY: Oxford University Press.CrossRefGoogle Scholar
  9. Engster, Daniel. 2007. The heart of justice: Care ethics and political theory. Oxford: Oxford University Press.CrossRefGoogle Scholar
  10. Fineman, Martha Albertson. 2004. The autonomy myth a theory of dependency. New York: New Press.Google Scholar
  11. Fineman, Martha Albertson. 2008 The vulnerable subject: Anchoring equality in the human condition. In Transcending the Boundaries of Law: Generations of Feminism and Legal Theory, 177–191. Abingdon: Routledge-Cavendish.Google Scholar
  12. Guo, Fei, and Wenshu Gao. 2008. What determines the welfare and social security entitlements of rural migrants in Chinese cities? In Migration and social protection in China, ed. Ingrid Nielsen and Russell Smyth, 118–137. Singapore: World Scientific.Google Scholar
  13. Hui, Jiang, Ye Wenqin, and Gu Yan. 2013. Family-paid caregivers in hospital health care in China. Journal of Nursing Management 21 (8):1026-1033.
  14. Kittay, Eva F. 2013. Love’s labor: Essays on women, equality and dependency. Abingdon: Routledge.CrossRefGoogle Scholar
  15. Li, Ye, Qunhong Wu, Chaojie Liu, Zheng Kang, Xin Xie, Hui Yin, Mingli Jiao, Guoxiang Liu, Yanhua Hao, and Ning Ning. 2014. Catastrophic health expenditure and rural household impoverishment in China: What role does the new cooperative health insurance scheme play? PLoS One 9 (4): e93253. Scholar
  16. Liu, Yuanli, Keqin Rao, and William C. Hsiao. 2003. Medical expenditure and rural impoverishment in China. Journal of Health Population and Nutrition 21 (3): 216.Google Scholar
  17. Long, Yan, and Lydia W. Li. 2016. “How would we deserve better?” Rural–urban dichotomy in health seeking for the chronically ill elderly in China. Qualitative Health Research 26 (12): 1689–1704. Scholar
  18. Meng, Qingyue, Jian Zhang, Fei Yan, Edward J. Hoekstra, and Jiatong Zhuo. 2012. One country, two worlds – The health disparity in China. Global Public Health 7 (2): 124–136. Scholar
  19. Schinkel, Anders. 2013. Justice and the Elderly. In Ethics, Health Policy and (Anti-) Aging Mixed Blessings, 1st ed. edited by Maartje Schermer and Wim Pinxten. Dordrecht: Springer Netherlands.Google Scholar
  20. Schmidtz, David. 2006. The elements of justice. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  21. Sevenhuijsen, Selma. 2003. Citizenship and the ethics of care: Feminist considerations on justice, morality and politics. Translated by Liz Savage. London: Routledge.CrossRefGoogle Scholar
  22. Temkin, Larry S. 1992. Book reviews: Arguing for equality, by John Baker. Philosophical Review 101 (2): 473–475. Scholar
  23. Tong, Rosemarie. 2014. Vulnerability and Aging in the context of care. In Vulnerability: New essays in ethics and feminist philosophy, ed. Catriona Mackenzie, Wendy Rogers, and Susan Dodds, 181–203. New York NY: Oxford University Press.Google Scholar
  24. Tronto, Joan C. 1993. Moral boundaries: A political argument for an ethic of care. New York, NY: Routledge.Google Scholar
  25. Turner, Bryan S. 2006. Vulnerability and human rights. University Park PA: Penn State Press.Google Scholar
  26. Yang, Wei. 2013. China’s new cooperative medical scheme and equity in access to health care: Evidence from a longitudinal household survey. International Journal for Equity in Health 12 (1): 20. Scholar
  27. Yangjiang Municipal Human Resources and Social Security Bureau. n.d., accessed on 13 March 2019.
  28. Yip, Winnie Chi-Man, William Hsiao, Qingyue Meng, Wen Chen, and Xiaoming Sun. 2010. Realignment of incentives for health-care providers in China. Lancet 375: 1120–1130. Scholar
  29. Zhou, Xu Dong, Lu Li, and Therese Hesketh. 2014. Health system reform in rural China: Voices of healthworkers and service-users. Social Science & Medicine 117: 134–141. Scholar
  30. Zimmer, Zachary, and Julia Kwong. 2004. Socioeconomic status and health among older adults in rural and urban China. Journal of Aging and Health 16 (1): 44–70. Scholar

Copyright information

© National University of Singapore and Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Bioethics CentreUniversity of OtagoDunedinNew Zealand

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