Responses to population ageing in the new era: a national condition report from China

Population ageing is the new national condition of China in 21st century. Responding actively to population ageing should be a long-term strategy of the country. This article introduces the process and characteristics of population ageing as the new national conditions and major challenges posed by it in the first session; in the second session, the author reviews the history of ageing policy system development since the founding of P.R.C. and presents the blueprint of a top-level strategy to respond actively to population ageing in the new era; session three of the article describes the major achievements of undertakings on ageing after 18th CPC national congress.


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Responses to population ageing in the new era: a national… The year of 2000 witnesses the commencement of an ageing society of China. Twenty-first century is marked as the era of population ageing. As shown in statistics of National Bureau of Statistics (NBS), by the end of 2017, the population aged over 60 years old reaches 241 million, accounting for 17.3% of the total population; population aged over 65 is 158 million, accounting for 11.4% of the total (Statistics from NBS 2018). As predicted in the 13th 5 Year Plan on Development of Undertakings on ageing and Old Age Support System by the State Council (2017 No. 13), by 2020, population of old persons would reach 255 million, thus the proportion of the total population would then be lifted up at least to 17.8%. Population of the oldest-old aged over 80 would increase to 29 million. Population of older persons living alone and empty nesters would increase to around 118 million. The old-age dependency ratio would be lifted up to around 28% (Official website of PRC Central Government 2017). According to the Main Report of National Strategy Respond to Population Ageing, the process of population ageing in China could be categorized into four stages (General research group of national strategy on population aging 2014).
Stage 1: From 1999 to 2022, there is a rapid development of population ageing, when population of older persons increases from 131 million to 268 million. The level of population ageing then would be lifted from 10.3% up to 18.5%. Stage 2: From 2023 to 2036, there will be an accelerating development of population ageing, when population of older persons will amount to 423 million increased from 268 million. The level of population ageing increases from 18.5 to 29.1%. Stage 3: From 2036 to 2053, progressive population ageing emerges. The size of old population will peak to 487 million. The level of population ageing then will increase up to 34.8% starting from the level of 29.1%. Stage 4: From 2054 to 2100, population ageing reaches a plateau, when the increase of old population stops. The size of old population shrinks from 487 million to 383 million, and the level of population ageing is stabilized at the level of around 1/3 ( Fig. 1).
China is now on its initiating stage of population ageing, though the absolute number and the comparative proportion of old population increase rapidly, whereas labor supply is still adequate and dependency ratio is comparatively low. Therefore, this is the period when opportunities arise to respond to future challenges to be posed by population ageing. On May 27, 2016, CPC's 32nd workshop on trends and responses of population ageing, President Xi Jinping delivered an important speech to summarize the attributes and characteristics of population ageing of our country (Official website of PRC Central Government 2016a). "Population Ageing is a global issue. Its impact toward human society is enduring and profound. China is one of the countries whose population is most aged in the world. The size of old population is one of the biggest in the world, and the speed of ageing process is one of the quickest, thus the tasks to respond to population 1 3 ageing is one of the most challenging. To meet needs of old population with tremendous size in all aspects, and cope with social issues brought by population ageing properly, are pertinent to strategic development of China and welfare of the public, which justifies our responses with strong commitment." To sum up, the size and proportion of old population of China present a pattern commenting with rapid increase, followed by a slowing down increase, then after reaching the peak, it shows a trend of a stable progress with slight decrease. To be short, population ageing in China is irreversible. It is a new national condition of 21st century. Population ageing is posing tremendous challenges in social and economic life of the country now and will be so for a long period of time in near future.

Characteristics of population ageing as the new national conditions
China is one of the most aged developing countries in the world. Comparing to other countries, the characteristics of population ageing could be summarized with below five attributes: (a) Huge size of elder population By 2013, population over 60 years old in our country has reached the amount of over 200 million. It is predicted that it would amount to 300 million in 2025, and 400 million in 2033. People 65 years and older has reached 116 million in 2010, and is predicted to be above 200 million in 2026. After that, the pace of the increase would accelerate. In 10 years-time, population over 65 would reach almost 300 million, and stabilize itself around the level of 377 million in 2060 (General research group of national strategy on population aging 2014). (b) Rapid pace of growth Besides Japan, China is the country ages the fastest during the process of drastic development. The level of population ageing will increase from current 1/7 to 1/3 till mid 21st century. Demographic transition in China is unprecedented as Responses to population ageing in the new era: a national… for most developed countries in the world, it usually takes more than 100 years, whereas, it only takes 40 years in the beginning of 21st century in China. (c) Massive population of oldest old According to the projection, by mid this century, the population of old people over 80 years would exceed 100 million, accounting for 22.3% of the total early population aged 60 and above. Then population of oldest old of China could equal to the amount of oldest old of all developed countries. (d) Evident disparities of ageing The amount and proportion of old population's increase is affected by process of uneasy demographic development of China (Lu and Guo 2016). While population of different age cohort ages, population newly added to the old group would fluctuate the old population in amount accordingly (Lin 2018). Therefore, the trend of development shows characteristics of sometimes fast sometimes slow. (e) High volatility of ageing The proportion of Chinese older persons is volatile because of the changing rate of population growth in different historical periods.

Grim challenges posed by population ageing
Population ageing is a triumph that all human beings enjoying together in 21st century, while at the same time, it poses major challenges that people need to face together. Opportunities provided by population ageing in China could easily elapse (Dang 2018). China is faced with risks to be brought about by population ageing in near future.
First of all, population ageing gradually becomes the primary contradiction in the area of population as a major socio-economic development of the society. The new contradiction of population ageing in the new era lies between the growing needs for better life and the inadequate development of the undertakings on ageing and the old-age service system (Lu and Zhang 2018). To be concrete, the contradiction is reflected in below 5 aspects: (1) The contraction of incompatibilities between demand and supply during the process of development of undertakings on ageing and elderly service system; (2) The contradictions between different regions and rural vs. urban areas in process of population ageing and development of elderly service system; (3) The contradiction amongst shift demographic dependent structure and intergenerational relationships; (4) The contradiction of increasing needs for support from families and diminishing capacity of family support; (5) The contradiction of practical needs from elderly group and inadequate provision of social governance support (Lu 2018).
Secondly, the potential risks of over load of population ageing emerge. Two critical issues of population and development in China are population ageing and low fertility rate. Population ageing lifts up the old age dependency ratio, and increases the potential burden of social development. Low fertility rate results in substantial decrease in working age labor and further increase of social dependent burden. As irreversible as ageing in China is, the fertility policy in China has not been fully relieved, that indicates there are policy opportunities to guide correction of low fertility rate. Fertility level in China maintains at a very low level for a long time. Efforts are needed to bring the low fertility rate to a level closer to replacement level. Abiding by the rules of demographic development and process of population ageing, government should be prepared in an active manner to surge of population ageing, otherwise, the window of opportunities would be closed very soon.
Thirdly, gaps of demands and needs further expand, and needs for medical care service from the public is booming. Drastic social development, tremendous base of population, and complexity in demographic structure, would pose continuous challenges to old age service system. In particular to older persons living in rural areas, huge gap for old age support service exists. So far, the coverage of our old age support system can only cover civil servants, staff of state-owned enterprises, public sector staff and staff from selected enterprises. Most of older persons in rural areas cannot enjoy social security service. Among those living in urban areas, there are less 30% of the total who could enjoy retirement wage. In recent years, coverage of social security has been tremendously increased by the State, however, the goal of "those who should will be insured" cannot be fully achieved yet. In the meantime, needs of older persons cannot be fully met by services provided by existing ageing undertakings and elderly service system. The efforts to improve management of chronic disease and professional care are progressing slowly. We should enhance the accuracy, efficiency and effectiveness in reforms to develop old age service industry (Lu 2018).

History of development of policy system on ageing in China and the strategic vision
Ever since the founding of P. R. China, according to national scenarios in different historical periods, adopting theories and concepts from other countries whose policies are advanced, China has established a comparatively complete policy system with China's characteristics and national situation (Yuan 2015). In response to the new normal state of population ageing, the society needs to make principle strategic options, proposes new blueprint to set up an ageing policy in the new era (Wu and Yao 2002), describing the new landscape to actively respond to population ageing. To be brief, the development would be categorized into below four stages.

Initiating stage to establish ageing policy system (1949-1977)
In this stage, there was no clear definition for "ageing", and nor well-developed policies and/or regulations in China on ageing exist. In the Constitution, safeguarding older persons' lawful rights and interests was mentioned briefly. People conducted initiative explorations on policies and regulations to support older persons on provision of medical care and assistance (Chen and Pang 2004). Ageing policies promoting "the elderly shall be supported" and "the elderly shall be secured" are emerging (Lu and Tang 2015).

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Responses to population ageing in the new era: a national…

Adjustment stage of ageing policy system (1978-1999)
After the 3rd Plenary Sessions of 11th Central Committee, governance of social and economic life of the country was normalized, and a variety of ageing policies was formulated and implemented. In 1983, National Working Commission on Ageing Issues was established demonstrating organizational and political commitment to implement work plans on ageing. In 1994, 10 ministries including National Family Planning Commission and Ministry of Civil Affairs jointly developed the 7-Year Programme (1994)(1995)(1996)(1997)(1998)(1999)(2000) of China on Ageing. In 1996, the promulgation of the Law on Protection of Rights and Interests of Older Persons of China signified ageing has been incorporated into political agenda of the Party and the government (Yuan et al. 2009). Ageing policy as an independent system is being institutionalized and legalized.

Policy system in primary shape (2000-2012)
In October, 1999, the State Council (SC) authorized the establishment of National Working Commission on Ageing (CNWCA) to take lead of coordination on undertakings on ageing. In 2001, the Decision to Strengthen the Work on Ageing was issued by the Central Committee of the Communist of China (CPC) and SC. In this decision, strategic directions toward strengthening undertakings on ageing and its policy system were identified. In the same year, the development plan on ageing entitled the 10th Five-Year Plan on Development of Undertakings on ageing of China was endorsed. In this stage, a policy system that is based on the Elderly Law, guided by 5-year plan of undertakings on ageing and social economic development, emphasizing the active response to population ageing emerged (Wu and Wang 2009). This system includes policies of older persons' welfare in different aspects including social security, elderly health, service, education, social participation, age friendly environment construction (Lin and Lv 2016).

Improvement of ageing policy system (since 2013)
In 2013, the 3rd Plenary Session of 18th Central Committee approved the Decision of the CPC on Several Major Issues to Comprehensively Deepening the Reform, in which, it was pointed out clearly that "respond actively to population ageing and accelerate the pace to set up old age support service system and develop elderly service industry, which signified responding actively to population ageing has become a long term development strategy with profound and strategic significance in the country (Li 2016 ministries. The policy system to respond to ageing of our country is evolving and becomes more sophisticated (Li 2018). The areas of ageing policies are expanding extensively with more precise contents (Zhai et al. 2016). Ageing policies enters into a whole new development stage in this period. Undoubtedly, ageing has become a new normal state of modern society of the country, new national contexts for decision making. Therefore, consideration of the issue of ageing should be brought up to a national strategic level, and guiding principles are needed for taking actions (Yuan 2015). Responding actively to population ageing, should not only focus on current practical problems to meet needs of old people according to short term planning, but also prepare for the future even more aged society in advance through a mid-long term visionary plan (Gu 2015). According to the process, trends and characteristics of certain period of time, we need to identify niche points and priority areas of work, and set up a long term governance module and system in line with trends of population ageing. We should shift mindset, improve current ageing policy system and social service system with comprehensive and holistic view to set up top-level design and strategic plan to respond to population ageing. In the new era, we should actively respond to population ageing in 4 areas including regulatory preparation, institutional arrangement, policy system, environmental construction, ageing education so as to set up strategic system and top-level design to take four actions to actively respond to ageing (Lu and Guo 2016), including develop mid-long strategic plan, improve social governance engaging multi-stakeholders, set up an age friendly environment and policy system, and conduct trainings on national situation on ageing.

Achievements of undertakings on ageing after the 18th CPC National Congress
Since the 18th CPC National Congress, to respond to the new normal state of accelerating population ageing, and to cope with challenges for reforms in different causes, considering new national contexts of national ageing with a view for future development, CPC centered by President Xi Jinping developed a series of major measures to speed up the undertakings on ageing and old age support system, thus, undertakings on ageing has experienced tremendous development. The first achievement is the top-level design of policies coming into shape. Since the 18th National Congress, the state is exploring innovative organizational arrangement to better respond to population ageing. In the year of 2013, the SC issued Opinions to Accelerate Old Age Service Industry for the purpose of setting up strategic blueprint for development of old age service industry, which is based on home, supplemented by community and supported by institutions. In 2016, with the implementation of "universal two child policy", relief of fertility policy could mitigate ageing in population development to some extend in a long run. In chapter 65 "actively respond to ageing" in the 13th Five-Year Plan for Social and Economic Development, it was clearly highlighted that we will take actions to respond to population ageing, strengthen top-level design and constitute a responsive system supported by demographic strategy, fertility policy, employment policy, old age service, social security system, health support, training of personnel, enabling environment and social participation (Official website of PRC Central Government 2016b). In the same year, State Council issued Opinions to Integrate Basic Health Insurance System of Rural and Urban Residents to uniform basic health insurance system of rural and urban residents. In March 2017, the 13th Five-Year Plan for Development of Undertakings on Ageing and Old Age Support System was issued, in which targets described as "4 basis 8 pillars" have clarified periodic arrangements (Lu et al. 2017). In June 2017, General Office of the State Council published Opinions on Development and Implementation of Project to Provide Older Persons with Care Service. The Opinions provided a checklist of focus areas and priority tasks to provide care services to older persons in line with China's contexts according to older persons' needs for service (Yuan 2017). In line with the opinions, in the report of 19th CPC National Congress, it was reiterated the requirements of "actively respond to population aging, constitute social policy and environment promoting social virtues of respecting and supporting the elderly, promoting integrated medical health care, speed up development of undertakings and industries of ageing", echoing the development of ageing undertakings after 18th National Congress of CPC, provides policy guidance to respond to population ageing in a long period of time in the future.
The second achievement is that there is tremendous progress of legislation for elderly persons. With many years of development, China has initially established a legal system guided by the Law for Protection of Rights and Interests of Older Persons of China, supported by the Social Security Law of China to protect older persons' rights and interests, with laws, administrative regulations, local regulations, sectoral guidelines included. In order to better support older persons lawful rights and interests so as to better develop undertakings on ageing, the Law for Protections of Rights and Interests of Older Persons has been revised for the second time in 2013 with improvements on articulation of family support, social security, social service, social assistance, livable communities, social participation and legal liabilities. At local level, there are a lot of specific laws/regulations promulgated on issues of social old age support system and respect older persons. For example, Shanghai Municipal Regulations on Management of Institutions in 2014 and the late the same year Tianjin issued the Tianjin Municipal Regulation on Elderly Service Promotion and Beijing Municipal Regulation on Home-based Elderly Service issued in early 2015. However, comparing to most developed and some developing countries, legal system of China for older persons lags behind progress of population ageing in terms of pace of development and amount. Therefore, the state should learn from good practices on legislation for older persons of advanced countries, and speed up the pace of improving legal system for older persons.
The third achievement is reflected by the constantly issuance of public policies to support older persons. After 18th National Congress of CPC, the state and localities issued a variety of intricate and refined public policies on ageing that effectively promote the practices of ageing undertakings: (a) An integrated medical health care system has been improved. The forth achievement lies in the development of old age support service and social security system in shape. After the 18th National Congress of CPC, China has initially set up a multi-facet old age support system based on family-based old-age support, relying on community services and supplementary institutional care integrating medical health care, promoting internet plus old age support to continuously meet diversified needs of older persons. There are different items of work for older person advancing simultaneously, including but not limited to the pilot of progressively delay of retirement age, deployment of old age pension system of rural and urban residents, speeding up direct payment for costs occurred by hospitalization in localities other than locations of registered hukou, significant progress of trial of long term care system, conduct of social assistance, social welfare of older person.
The fifth achievement is reflected on innovative practices of localities. There are a lot of innovative explorations on integrated medical care services, long term care insurance and SMART ageing initiatives with evident achievement. For example, Shenzhen, to explore integrated medical health care service, has set up an integrated elderly service system comprised of home-based elderly care plus family sickbeds, community day care center plus community health service center, institutions plus specialized hospital (with geriatrics department). Another good practice is from Qingdao on piloting long-term care insurance which bears significant replication value. There are a lot of good practices promoting SMART ageing, such as "Huiyi-Tong" health service platform, integrated service platform provided by "96890" of Haiyang Group of Shanghai, and home based care provided by "mothers in candle light initiative" and etc.
In short, as the country with the largest elderly population in the world, China's social and economic development has been profoundly affected by the ageing population, China also faces increasing pressure to provide safe and affordable care for the elderly. Actively responding to population ageing has become an important national strategy of China. In order to achieve the "two centenary goals", this paper calls for further top-level design of the aging problem with the orientation of the basic national policy based on the principle of overall, comprehensive, persistent and forward-looking. Only in this way we can truly ensure the well-being of the elderly and the people of the country.