1 International MPA (I-MPA) Class of 2021 Capstone Report Caring for China’s Most Needy Elderly Citizens: Lessons from Three Cities Professor John J

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1 International MPA (I-MPA) Class of 2021 Capstone Report Caring for China’s Most Needy Elderly Citizens: Lessons from Three Cities Professor John J. DiIulio, Jr. and Professor Christine K. Bradway Class of 2021 Capstone Commissioner: Yulin Dai Leadership Task Group (LTG) Executive Committee: Anqi Sun, Bowei Zhang, Chuyi Chen, Kaixuan Han, Lingxi Huang, Shuyu Cai, Ying Zhou, Yulin Dai LTG Nanjing: Anqi Sun, Chuyi Chen, Jiaxin Hu, Kecen Liu, Lingxuan Yu, Ying Zhou, Zhixiao Zhang LTG Suzhou: Boyuan Zhang, Kaixuan Han, Xianghan Zhu, Xiaohang Li, Yanyingzi Wang, Yougeng Zheng LTG Shenzhen: Bowei Zhang, Jiaqi Wang, Lingxi Huang, Lu Liu, Shuyu Cai, Yulin Dai April 30, 2021 2 Contents Introduction ................................................................................................................................ 3 1. An Overview of Eldercare Services in Nanjing, Suzhou and Shenzhen ............................... 6 1.1 Nanjing..................................................................................................................... 6 1.2 Suzhou ...................................................................................................................... 7 1.3 Shenzhen .................................................................................................................. 9 2. An Overview of the Needy Elderly and Eldercare Policies and Projects in Nanjing, Suzhou and Shenzhen ........................................................................................................................... 10 2.1 Nanjing................................................................................................................... 11 2.1.1 Identification, Supporting Methods and Current Situation of the “Extremely Needy Elderly Citizens” in Nanjing. ............................................ 11 2.1.2 An Overview of PPP-Mode Eldercare Projects in Nanjing. ................... 12 2.1.3 Eldercare Projects for the "Three Needs" Sub-population in Nanjing. .. 14 Respite Service. .................................................................................... 15 Time Bank............................................................................................. 16 2.2 Suzhou .................................................................................................................... 19 2.2.1 Identification, Supporting Methods and Current Situation of the “Extremely Needy Elderly Citizens” in Suzhou. ............................................. 19 2.2.2 An Overview of PPP-Mode Eldercare Projects in Suzhou. .................... 21 2.2.3 Eldercare Projects for the "Three Needs" Sub-population in Suzhou. ... 22 Virtual Eldercare Center Program....................................................... 22 2.3 Shenzhen ................................................................................................................ 24 2.3.1 Identification, Supporting Methods and Current Situation of the "Extremely Needy Elderly Citizens" in Shenzhen........................................... 24 2.3.2 An Overview of PPP-Mode Eldercare Projects in Shenzhen.................. 26 2.3.3 Eldercare Projects for the Needy Elderly in Shenzhen. .......................... 27 3 Octagon House Eldercare Center in Futian District. .......................... 27 Rongyue (VankeCare) in Futian District and Nanshan District. ......... 28 3. Program Recommendations ................................................................................................. 28 3.1 Improved Time Bank .............................................................................................. 29 3.1.1. Program Evaluation ............................................................................... 32 Study Design. ....................................................................................... 33 Data Collection Plan. .......................................................................... 33 Data Analysis Plan. ............................................................................. 36 3.2 Other Proposals ..................................................................................................... 37 References ................................................................................................................................ 39 Appendix .................................................................................................................................. 47 Caring for China’s Most Needy Elderly Citizens: Lessons from Three Cities Introduction Today, China is home to the world’s largest elderly population in the world. At the end of 2019, China had 254 million citizens aged 60 and above. It is expected that China’s elderly population will exceed 300 million by 2025, surpass 400 million by 2040, and peak at 487 million by 2053 (Ministry of Civil Affairs, 2020). Tsinghua University’s Professor Yansui Yang, one of China’s leading experts on the subject, has characterized three main aging challenges in China as "aging before getting rich, rapid aging and deep aging" (Yansui Yang, 2021). In response to these challenges, the Communist Party of China (CPC) and China’s national, provincial, and district-level governments have enacted a host of eldercare-relevant laws, regulations, and guidelines over the last two decades (Appendix). The latest eldercarerelevant policies and plans are those articulated in 2021 on the foundation of the 14th FiveYear Plan for Economic and Social Development (Xinhua News Agency, 2021). One of the most far-reaching of these policies and plans has been, and continues to be, the "90-7-3" 4 protocol, which refers to the situation of having 90 percent of eldercare in home-based settings, 7 percent in community-service settings, and 3 percent in nursing home institutions (National Health Commission, 2021). Experts and the leaders who implemented China’s eldercare policies and plans agree that this nation faces steep challenges in caring for its large and growing population of senior citizens: a relative lack of home-based eldercare services and related professional health services; a serious shortage of nursing beds in eldercare institutions; a scarcity of age-friendly cultural and recreational products and services; a major shortage of professional eldercare nursing personnel; a lack of focus and programming dedicated to maintaining emotional well-being among the elderly; and others (Yushao Wu, 2020). In order to tackle these challenges and to respond to population aging more actively, the government formulated the National Plan for Actively Responding to Population Aging (State Council, 2019) and initially proposed in the 14th Five-Year Plan to implement a national strategy (Xinhua News Agency, 2021). An eldercare service system is thus formed with "home-based, community-based support, institutions as supplementary, and integrated medical and eldercare services" (Yushao Wu, 2020). In detail, China promotes the renovation of age-friendly facilities in homes and communities, enhances the training of eldercare talents, develops a “embedded eldercare mode” in communities, expands the supply of nursing beds in eldercare institutions, and generates a “publicly constructed and privately-run mode” (Xinhua News Agency, 2021). Meanwhile, the government formulated and revised several relevant laws such as the Law of the People's Republic of China on the Protection of the Rights and Interests of Elderly People and the Law of the People's Republic of China on the Promotion of Basic Medical and Health Care, and improved protections for needy groups (economic difficulties, disability, loss of independence) through an economic subsidies system and a visiting care system (Xinhua News Agency, 2021). 5 “Silver Hair Economy” is a term synonymous with the aging industry or industries related to the elderly population (Tencent, 2021). Due to the huge population base, fast aging rate, and strong government support, China's "Silver Hair Economy" is currently at a relatively early stage, especially in the eldercare, health and service industries. On the demand side, thanks to the growth in the GDP per capita, the government covers the old-age insurance on a nation-wide scale and gradually increases in pensions. The elderly and their dependents begin to have stronger purchasing abilities. Meanwhile, it is difficult for many elderly people to take care of themselves at home due to the decades-long one-child policy and China’s overall population mobility. They need eldercare institutions and professionals. People also begin to have higher requirements the quality of eldercare with the continuous development of modernization. Therefore, the elderly and their families have a higher willingness to pay. In a word, the absolute value of the slope of China's "Silver Hair Economy" demand curve is showing a rising trend. On the supply side, the core of the “Silver Hair Economy” is the entire industrial chain serving the elderly, but at present, China's retirement infrastructure is under-supplied. According to the China Aging Industry Development Report released by the National Committee on Aging, the potential consumption of China's elderly population will grow from 4 trillion yuan in 2004 to about 106 trillion yuan in 2050 (Sohu, 2019). Data shows that the number of endowment-related enterprises registered in China reached 27,400 in 2019, 561% higher than ten years ago (Sohu, 2020). Thus, China has the largest potential market related to the elderly in the world. Yet China's eldercare industry is still in the early development stage. The industry has not formed a complete business model, and its quality and quantity also need to be improved. “Silver Hair Economy” in the future will show the following trends. Firstly, the consumption ability of the elderly will be strengthened. The purchasing power plus the willingness to pay constitute the effective demand. Secondly, the industry will 6 include improved supply chain and characteristic services to meet the special needs of the elderly, such as at-home nursing, life security of the disabled elderly, and so on. Thirdly, the policy system of the “Silver Hair Economy” will increase the efforts to support from different aspects, such as finance, taxation, finance, land, etc. Through the analysis of news, reports, lectures, and scholarly literatures, this report examines the eldercare challenges in China’s three major cities—Nanjing, Shenzhen, and Suzhou. These cities were chosen for examination according to the I-MPA faculty members and advisers from the University of Pennsylvania—Tsinghua University Joint Project on Eldercare in China (J-PEC). The first part of this report introduces Nanjing’s, Shenzhen’s, and Suzhou’s eldercare challenges and offers an overview of their respective eldercare service systems. In the second part, we outline how the three cities identify the "Extremely Needy Elderly Citizens.” In the third part, we review each city’s existing initiatives to address the "Three Needs" subpopulation’s needs, with special attention paid to the public-private partnership (PPP) projects. Finally, we summarize the lessons learned from the three cities, and generate program recommendations which we believe can be replicated and feasible in other cities. 1. An Overview of Eldercare Services in Nanjing, Suzhou and Shenzhen 1.1 Nanjing According to reports, the registered permanent residence of Nanjing was 6,487,200. There are 1,581,000 elderly people aged 60 and over in Nanjing, accounting for 24% of the total household registration population (Modern Express, 2020). The elderly population is growing at a rate of about 40,000 people a year. The aging rate manifests the growing pace of an aging population. Therefore, Nanjing was one of the major cities in China with serious aging. The aging process in Nanjing presents important characteristics: "early entry time, fast 7 growth, and high comprehensive quality" (China Jiangsu Net, 2017). Meanwhile, with the growing urbanization, the aging situation in Nanjing will become more and more severe in the next few decades (Nanjing Statistical Bureau, 2017). In response to the problem, the Nanjing Municipal Government has issued several policy documents, such as Opinions on Enforcing the Service for the Aged, and Notice on Supporting the Integration and Transformation of Unused Social Resources to Develop the Service for the Aged, to achieve objectives such as creating artificial intelligence platforms, training professional service workers, improving the quality of the eldercare institutions, and promoting the development of the industry for the aged (Nanjing Statistical Bureau, 2017). In recent years, the retirement services in Nanjing has developed into eldercare complexes, such as eldercare in communities and projects combining the medical and eldercare services (Modern Express, 2020). According to the Service Status of Medical and Eldercare Services in Nanjing Old-age Aging Institutions, Nanjing has 12 rehabilitation hospitals, 50 nursing hospitals, 81 nursing stations and 108 institutions specializing in the integration of medical and eldercare services (Modern Express, 2020). Although this integration approach is comprehensive, yet minority needs still remain unmet. This is where the non-profit organizations comes into place, as they help “close the gap between public and private sector actions, serve an under-served client group that often falls through the cracks, and have needs that are not met by the other sectors" (Forrer et al, 2014). Therefore, the cooperation between the government and non-profit organizations contribute to innovative eldercare modes. 1.2 Suzhou Suzhou is a city located in the southeast of Jiangsu province. In 2018, Suzhou had 7,035,400 registered households and 1,830,900 elderly people, accounting for 26.02% of the 8 total registered household population. 15.39% of the elderly population are over 80 years old (Yangtze late report, 2019). In 2020, Suzhou had 7,443,300 registered households and 1,884,900 elderly people aged over 60 years old, accounting for 25.32% of total registered household population (Tencent, 2021). Although the proportion of the elderly in the total household registered had declined, the mechanical growth rate of population in Suzhou in 2020 reached 27.95%, which was 3.62% higher than 24.33% in 2019 (NetEase, 2021). The large increase of the household registered had diluted the proportion of the elderly. Overall, as the oldest city in Jiangsu (China Aging Association, 2019), Suzhou still faces the challenges of aging in the future. In response to its population aging, the Suzhou government has issued several policies, such as Suggestions on Speeding Up the Development of Old-age Services in Suzhou, Suggestions on the Implementation of the Regulations on Home-based Old-age Services in Suzhou. The government endeavors to not only promotes filial piety but also improve the eldercare industry (Chinese civilized network, 2018). Suzhou has developed a unique nursing service system, which includes the combination of home nursing and Internet nursing services, community eldercare, and eldercare in enterprises and social organizations. An outstanding example of the system is the virtual nursing home built on information technology. In detail, while Suzhou’s Gusu District had been exploring the socialized home-based eldercare service since 2003, it then took the lead in introducing information technology into home-based eldercare services and first proposed the concept of virtual eldercare services in China in 2007. This virtual nursing home targets those who are aged over 75, live in empty nests, and whose self-living ability is gradually decreasing (360doc, 2020). Until now, the virtual service center has 419 employees and serves 1.2 million people and 26,000 people. In general, technologies, such as the Internet and artificial intelligence, help improve the efficiency of the eldercare service in 9 Suzhou. 1.3 Shenzhen Shenzhen is the first Special Economic Zone and known as the youngest city in China. In 2019, the elderly population aged 60 and above in Shenzhen was 337,600 (Shenzhen Civil Affairs Bureau, 2020), accounting for 6.80% of the registered residence population. The percentage is lower than the standard of the aging society (10%) and lower than the proportion of China's aging population (18.10%) (Shenzhen City Bureau of statistics & Shenzhen Investigation Team of National Bureau of statistics, 2020). Despite this, the aging problem in Shenzhen is still the focus of the Shenzhen government's work, one of the prominent reasons is that the group of people who built the Special Economic Zone in Shenzhen three or four decades ago will soon enter the aging stage. Considering aging rate in Shenzhen and the number of elderly people without household registration, it is predicted that the number of elderly people with household registration in Shenzhen would reach 710,000 and the number of elderly people with permanent residence would reach 1,300,000 in ten years (Shenzhen Civil Affairs Bureau, 2020). Therefore, although Shenzhen was not an old society now, the worry of "getting old before getting rich" still existed. Additionally, the development of the nursing home in Shenzhen didn't match the growth of the elderly. From 2013 to 2017, the eldercare institutions only increased from 28 to 35, including bed numbers from 2,919 to 8,247 and the year-end population housed from 2,340 to 3,384 persons (Shenzhen City Bureau of Statistics & Shenzhen Investigation Team of National Bureau of statistics, 2020). From 2017 to 2019, the eldercare institutions has grown from 35 to 47, with 10,209 beds and 4,303 housed population (Shenzhen City Bureau of Statistics & Shenzhen Investigation Team of National Bureau of statistics, 2020). To tackle the potential aging challenges, Shenzhen has issued a series of policies and 10 regulations, including the Five-Year Implementation Plan for a high-level "1336" Elderly Service System and the Regulations on Elderly Services in Shenzhen Special Economic Zone. According to the policies, Shenzhen will develop a comprehensive and multi-level eldercare service system, covering the aspects of home-based and community-based eldercare services, eldercare institutions in PPP mode, and a long-term care insurance system. The plan also integrates eldercare service with medical care. Therefore, although Shenzhen is yet to age, the government’s layout for aging has already been at the forefront of the country. A horizontal comparison of the three cities shows that the proportions of the elder population in Nanjing and Suzhou are similar, but the number of eldercare institutions in Nanjing is significantly higher than that in Suzhou. While Shenzhen is far less elderly than Nanjing and Suzhou, and the number of eldercare institutions is lower than other two cities, meaning Shenzhen’s eldercare services have greater growing space. 2. An Overview of the Needy Elderly and Eldercare Policies and Projects in Nanjing, Suzhou and Shenzhen This paper focuses on the Most Needy Elderly Citizens. Among them, the "Three Needs'' sub-population refers to the following senior groups: 1) those who need attention for serious medical problems or debilities; 2) those who need in-home, community-based, or residential/nursing home care, services, and supports by family members, neighbors, health care professionals, or others; 3) those who need adequate and financial or other tangible resources. Based on these criteria, “????? [The Extremely Needy Elderly Citizens]” frequently used in China’s official documents is similar to the term “Three Needs'' subpopulations, meaning marginalized elderly populations needed extra attention and professional support. Nanjin...