Reform and Reconstruction of the Rural Elderly Care Service System in the New Era

Abstract:With decades of hard work,socialism with Chinese characteristics has crossed the threshold into a new era.The transformation of the principal contradiction in the new era has imposed new and higher requirements on the rural elderly care service system.However,the current service system based on welfare-multiplex and urban community environment is often difficult to operate in the rural areas of central and western China.And the urban home care service for the aged is inappropriate to the rural reality;community service for the aged faces difficulties in practice;institution care for the aged develops slowly;the synergy among different elderly care service models is poor.Through observing the rural areas of central and western China in the field for a long time,this paper proposes to build the rural elderly care service system based on family supporting,supported by community mutual assistance care,supplemented by institution care for the aged,combined with medical care,and localized with diversified forms for targeted groups according to different realities.And the system should follow the fundamental guidance of development-oriented family policy,adhere to the governance mode of multiple subjects with one core and respect rural reality,which could provide a feasible way for the reform and reconstruction of the rural elderly care service system.

Key words:new era;development-oriented family policy;governance mode of multiple subjects with one core;the rural elderly care service system

According to the international standard of aging which defines that a country with 10% of the total population over 60 years old enters an aging society,it is no doubt that China has been a country with a large aging population.In the new era of highly aging and getting old before getting rich,the demand for elderly care service of the whole society keeps expanding,but the supply of elderly care service in the society is obviously misplaced,which leads to increasingly prominent problems of structural contradictions between supply and demand of elderly care service.Facing the severe aging situation,the 13th Five-Year Plan proposed to establish a multi-level elderly care service system based on the home care service for the aged,supported by the community service for the aged and supplemented by institution care for the aged and promoted the combination of medical care service and elderly care service in order to find a appropriate solution to the elderly service for the aging population.However,as the elderly care service system is essentially designed on the basis of the urban community environment,it is difficult to operate in the rural areas of central and western China.The rural elderly care service relevant to the daily life of hundreds of millions of the elderly living there has become a major weakness for China’s elderly care service as a whole.Therefore,it has become one of the major social problems to be solved in the new era to deeply reform and reconstruct the rural elderly care service system in combination with the reality in the rural areas of central and western China.

Ⅰ.The new requirements for the rural elderly care service system in the new era

1.Establishment of development-oriented family policy

Since the 1990s,the social policy tendency of returning to the family gradually appeared in western countries,and many social policies have tended to support the family,thus the development-oriented family policy took shape.〔1〕At the conference commemorating the 20th Anniversary of the International Year of the Family,Sam Kutesa,President of the United Nations,pointed out that the value orientation of global family policy was undergoing two important transformations.One of them is the transformation of family’s self-reliance into the common support of society and government.The other is the transformation of supportive family policy into the development-oriented family policy.However,since China’s reform and opening up,Chinese society has been troubled by the paradox of the family policy for a long time.On the one hand,families bear the burden of supporting the elderly and children;on the other hand,for a long time,China’s rural support policies have taken the per capita income or having-or-having-no child as the standard to determine whether to give support for a family.As a result,vulnerable families with heavy burdens of supporting the elderly and children can hardly get social support due to policy barriers.〔2〕After entering the new era,the internal and external risks faced by rural families will continue to increase.From the perspective of family’s interior,the stability of family’s internal structure has been undermined for empty nest household,migrant families and long-distance families,which has increased the risk of family breakdown.From the perspective of family’s exterior,the aging and the senility of the population have increased the pressure of family support,and the increasingly commercialized supply like medical care and education has intensified the pressure of family survival and development,which may lead to the crisis of family disintegration.However,if we completely rely on the government and the market to provide elderly care service,it will be hard to ensure the effective supply and the financial pressure of the government will also be increased.Therefore,emphasizing and supporting family development and making clear the policy orientation of developmental family policy should be top priorities in the development of rural elderly care service.The establishment of development-oriented family policy will change the traditional practice of China’s social welfare,which is to provide the last safety net after people have fallen into the marginal groups instead of preventing it from happening by providing support beforehand.Development-oriented family policy can provide help for vulnerable groups in trouble,and what’s more,it can help them strengthen the ability to adapt to economic and social changes through measures of prevention,support and early intervention.

2.The creation of governance mode of multiple subjects with one core for the elderly care service

The elderly care service system proposed in the 13th Five-Year Plan has encountered enormous problems in the process of rural practices,such as the absence of government responsibility,lack of coordination among multiple subjects as well as structural supply and demand contradictions of the elderly care service.The reasons for this situation include the following three aspects.Firstly,emerging after the fiscal crisis of the welfare states,welfare-multiplex was proposed by western governments to reduce their own responsibilities and strengthen the responsibilities of individuals,families and society.〔3〕However,in the rural areas of central and western China,the elderly care service resources are still very deficient.Therefore the government service should be expanded rather than reduced.In the rural society of central and western China where power and responsibility are asymmetric,the blind implementation of welfare-multiplex has resulted in the free riding and unfulfilled responsibility of the government.〔4〕Secondly,for a long time,the government’s policy tendency of valuing cities over rural areas has led to deficient service resources,underdeveloped infrastructure,and shortage of the hardware facilities,talents,medical and technical resources that are necessary to develop the urban home care service and community service for the aged in the rural areas.Thirdly,the profit of rural elderly care service is relatively low.Without the financial support from the government,the enthusiasm of institutions and social organizations to participate in the supply of rural elderly care service will inevitably be frustrated,so the role of multiple subjects will not play well.Therefore,the urban elderly care service system based on welfare-multiplex is difficult to meet the objective needs of rural elderly care service,and the solution to problems for supporting the rural elderly should be based on the actual rural environment and guided by the governance mode of multiple subjects with one core.What is called governance mode of multiple subjects with one core?Actually,one core refers to the government,and multiple subjects refers to other subjects including families,communities,social organizations and markets.In the governance mode of multiple subjects with one core,the government plays multiple roles of manager,producer,agent and supervisor,takes responsibilities for making the overall plan for the elderly care service system,provides basic elderly care service resources,distributes the right and obligation of each service subject and supervises the implementation effect of service projects,which plays a central role of commanding the whole situation.〔5〕Occupying the key position,the government shall not follow the old way of taking all-round responsibilities as it did before,but focus on improving the rural elderly care service system as well as coordinating and optimizing the relationship among multiple subjects.Except some necessary elderly care services such as subsistence allowances,the five guarantees should be provided by the government directly,other services should be provided by other subjects in the form of government purchase.

3.The establishment of the rural elderly care service system based on rural conditions

Due to the differences between urban and rural areas,the construction of the rural elderly care service system is also different from that of the urban elderly care service system.The construction of the elderly care service system in rural areas should conform to the rural practice and should be coordinated with local economic development level,pension cost and traditional culture.In eastern regions and urban communities with good economic conditions,the elderly care service dominated by the social service system can be properly adopted to give full play to the positive role of market players.However,in the rural areas of central and western China,where the economy is relatively backward and the cultural tradition is relatively conservative,the elderly care service based on family supporting should still be developed,and the role of the government as a guarantee should be highlighted.Therefore,the research holds that it should be a feasible way to build the rural elderly care service system based on family supporting,supported by community elderly mutual assistance care,supplemented by institution care for the aged,combined with medical care,and localized with diversified forms for targeted groups according to different realities.Emphasizing on family supporting conforms to the economic development level and traditional culture in the rural areas of central and western China.It is also an important measure to relieve the financial pressure of the government and improve the living quality of the elderly in rural areas;community mutual assistance care for the aged is a model customized for rural area with characteristics such as weak infrastructure but good tradition of mutual assistance among rural neighbors;promoting the development of institution care for the aged is to meet the special service needs of rural elderly who are disabled,mentally retarded,aged,seriously ill,living on subsistence allowances and suffering poverty;integrating medical care into the rural elderly care service system is to meet the increasing medical and nursing needs of rural elderly;localized,diversified and targeted service system is beneficial to solve the problems of overlapping and chaotic in function positioning,service objects and service contents between different service models.All in all,such an elderly care service system suitable for rural reality can effectively meet the needs of the elderly in the rural areas of central and western China,and can be a feasible way to solve problems for supporting the rural elderly.

Ⅱ.The practical dilemma of the current elderly care service system in rural areas

1.The practical difficulties of community service for the aged in rural areas

Community service for the aged often serves as a supplement and support for home care service for the aged,mainly providing community day care and support service for the elderly and aiming at the temporarily or continuously unattended elderly in the community.Like home care service for the aged,community service for the aged in rural areas is also faced with many practical problems,such as the shortage of funds of day care centers,low coverage rate and low level of service,and the establishment of fee-based community service for the aged is even more difficult in rural areas.According to The Statistical Bulletin of China Social Service Development in 2017 issued by Ministry of Civil Affairs of the People’s Republic of China,by the end of 2017,the coverage rate of urban community service centers in China was 78.6% while that of community service centers in rural areas was 15.3%.〔6〕The reasons for the low coverage of community service for the aged in rural areas are as follows.Firstly,there’s no sufficient fund investment.Community service for the aged mainly depends on government investment or collective sector,while the rural collective sector is weak with the financial difficulties of local governments and the insufficient input of central government,etc,leading to a lack of basic financial support for community service for the aged in rural areas.Secondly,effective demand is insufficient.The unsupported elderly who are the focus of community service for the aged have low income,and the rural elderly are resistant to the practice of paying for service,which makes it difficult for the market and social organizations to play important roles.Thirdly,the quantity and quality of community service personnel are insufficient.The social work profession in China is still in the developmental stage,with insufficient quantity and low service level.The professional talents who are willing to work in the rural areas of central and western China are extremely rare,and it is difficult to form a stable talent support team.As a result,it is difficult for the urban type of community elderly care service to develop in rural areas,basically difficult to implement.

2.Slow development of institution care for the aged in rural areas

At present,the rural elderly nursing institutions in China can be basically divided into three types:public institutions,state-owned and privately-operated institutions,and private institutions.Except for the public institutions funded by the government,the development of rural private institutions is relatively slow.The public data released by the Ministry of Civil Affairs point out that only half of elderly nursing institutions in China barely make ends meet,40% of them suffer long-term losses,and less than 9% of them make profits.〔7〕In addition to the problem of making less profits,the privately-operated institutions also face many problems,including staff shortage,low service level and high accident risk.With the severity of aging population,the potential demand for nursing institutions in rural areas is enormous,but the service supply of institution care for the aged has shown significant deviations.This kind of deviation is mainly reflected in three aspects:firstly,the per capita bed for the elderly is low,but the vacancy rate of the bed in the elderly nursing institutions is still high.According to The Statistical Bulletin on China Social Service Development in 2017 released by the Ministry of Civil Affairs,there are about 30.9 beds for 1,000 elderly people in China while there are about 50-70 beds for 1,000 elderly people in western developed countries.Moreover,nearly half of the beds in nursing institutions in rural areas are still vacant.Secondly,the public institutions are in short supply while the supply of private institutions exceeds the demand.The public institutions enjoy various policy benefits and preferences,making the private institutions gradually marginalized and hardly to survive with little development space.Thirdly,there are more high-grade and low-grade nursing institutions,and less mid-grade ones in China.Low-grade nursing institutions can attract some rural elderly people because of their low prices,but they are of poor facilities,substandard health and fire-fighting facilities,high security risks.What’s worse,the government tends to turn a blind eye and subjectively relax supervision under the pressure of supporting the aged.On the contrary,high-grade nursing institutions are likely to be vacant because of the high fees,which the ordinary rural elderly can’t afford while the elderly with good economic conditions are unwilling to choose because they can employ nursing workers to take care of them at home.〔8〕

3.Poor synergy among the different models of service for the aged

One of the biggest problems of the current rural elderly care service system is the confusion caused by the unclear definition of rights and responsibilities among the elderly service providers and the unclear function positioning among various elderly service models.Firstly,responsibilities and obligations are not clearly divided among government,community,family and market and the functional positioning among them is overlapping and confusing.In the elderly care service system,sometimes the government is in a state of absence,such as ineffective policy formulation and implementation,insufficient interaction between multi-sectors and inadequate supervision.Other times the government is in a state of overrun,which can be seen in the preferred support for public nursing institutions while ignoring the role of social organizations.Meanwhile the government is in a state of dislocation,for example,setting up luxurious nursing homes and competing with private elderly care institutions.Unclear positioning and confused rights and responsibilities of the various elderly care service providers have failed to form a sound synergy among the government,community,family and market,which makes it difficult to establish a cooperation mechanism among the four major service providers.〔9〕Secondly,all elderly care service models just lead their own ways and lack of coordination,as a result,their service objects are basically overlapped.For example,the current home care service,community service and institution care for the aged are for all rural elderly without focused segment.Various elderly care services in rural areas get on with their own jobs,leading to some problems such as insufficient functioning in resource sharing and complementary advantages,lack of communication platform and integrated mechanism,all resulting in traditional and single elderly service system unable to meet the demand of the elderly for multi-level and diversified services with fragmented system and isolation in system formulation and implementation.〔10〕Considering these problems,the functional positioning and the division between rights and responsibilities of each elderly service providers should be clarified when carrying out the reform of rural elderly care service system in China.Secondly,the service objects,service contents and service scope of various rural elderly care service models should be rigidly distinguished to set up a scientific and reasonable elderly service system in accordance with the rural practice.The study holds that the cooperation among multiple subjects should adhere to the principle of “governance mode of multiple subjects with one core”.Playing a central role as planner,promoter and supervisor,the government is responsible for coordinating the relationship between multiple subjects and improving the overall level of elderly care service.Community,as a subsidiary service provider,provides an auxiliary care service for the unattended elderly in the community.Family,as a basic service provider,provides the basic services for the majority of rural elderly.The market,as a complementary service provider,focuses on caring for the poor rural elderly unable to be attended by families and communities.For the positioning of the service objects,the service scope of various elderly care service models should be redivided by self-care ability of the receivers and whether their children are taking care of them.

Ⅲ.The construction of the elderly care service system in the new era

The elderly care service system in China consisting of urban and rural elderly care service system is based on home care service,supported by community service,supplemented by institution care for the aged,and combined with medical care,has comprehensive functions and appropriate scale,and covers both urban and rural areas.However,as far as the actual situation is concerned,urban and rural communities have different social environments,living habits and cultural traditions.Therefore,it is necessary to adjust,refine and reconstruct the rural elderly care service system in combination with the unique rural living environment.The study suggests that the construction of China’s current rural elderly care service system shall follow the development-oriented family policy,governance mode of multiple subjects with one core as the service participator models,and discuss the reform and reconstruction of rural elderly service system,eventually establishing the rural elderly service system based on family supporting,supported by community mutual assistance care,supplemented by institution care for the aged,combined with medical care,and localized with diversified forms for targeted groups according to different realities.

1.Rural elderly service system based on family supporting

Family supporting for the aged emphasizes the support for rural families to provide support for the elderly.Its core concept is to support the family,but it does not exclude the state and other subjects from providing service for the elderly.Family supporting for the aged is the essential requirement of the development-oriented family policy and a natural choice under the rural practice environment.On the one hand,the development-oriented family policy emphasizes that we should improve the development ability of the family and provide adequate support for the family both internally and externally.〔11〕On the other hand,family supporting is still an inevitable choice for the elderly service in the rural environment for a long time.Due to the backward economy,deep-rooted traditional culture and weak infrastructure,the rural areas in the central and western regions still do not have the objective conditions to develop home care service and community service for the aged which have been well developed in urban area.Family supporting will remain the basic support model in central and western rural areas for a long time.To adhere to and improve the family supporting,the government is required to establish all-round family supporting policies,including setting up family care allowances,encouraging families to purchase long-term care insurance,establishing a home leave system,implementing the policy of housing security for large families,and formulating preferential tax policies for rewarding the behaviour of support.All these policies can effectively enhance the ability of family to support the elderly and give full play to the basic role of family supporting for the elderly.

2.Rural elderly service system supported by community mutual assistance care

With the increase of empty-nest families and the left-behind elderly,the government has invested in the transformation of idle land and houses within the village in rural areas into nursing homes and bears daily operating expenses,forming a model of community mutual assistance care for the aged in which the elderly care for each other,such as the Mutual Assistance Happiness Home in Feixiang County,Hebei Province,the Charity Happiness Home in Wuzhi County,Henan Province and elderly care service stations in Luoshan,Henan.The model of mutual assistance care for the aged in rural communities has outstanding value in exerting the value of the elderly,reducing economic costs,enhancing community cohesion,and improving the elderly care service system.Such a model has been proved to be an important development direction for the future rural communities in China.In general,community service for the aged mentioned above refers to urban communities,and community mutual assistance care for the aged is more common in rural areas.For community service,better supporting infrastructures are required,such as fitness facilities,day care centers,and on-site service.At present,such problems as high loss rate of rural fitness facilities,shortage of funds for day care centers,and non-acceptance of on-site service by farmers have gradually emerged,making it very difficult to popularize community service for the aged in rural areas.Therefore,it is reasonable to encourage the community mutual assistance care model in the rural areas of central and western China with less expenditure,better service and practice in line with the farmers’ tradition.Such a model should become one of the important components of the rural elderly care service system in China.However,there are still some problems such as unclear legal status,high operational risks,and reliance on the financial support of the government with the model.Therefore,it is necessary to carry out and further reform in improving relevant laws and regulations,reducing safety risks and broadening financing channels.

3.Rural elderly service system supplemented by institution care for the aged

With increasing aging population and the outward shift of the function of the family supporting in rural areas,the demand for institution care in rural areas will continue to grow.However,under the background of insufficient financial capacity of the primary-level government,limited special investment from the central government and increased service supply gap,it is not enough to promote the development of institution care by relying solely on the government.Therefore,for the development of rural institution care,it has become an urgent task to formulate and implement relevant preferential policies,encourage social forces to set up private elderly nursing institutions,and innovate the forms and functions of institution care for the aged,so as to expand the effective supply of institution care in rural area.Faced with current inefficiency of public elderly nursing institutions,slow development of private elderly nursing institutions and sharp contradictions between supply and demand of institution care,it is necessary to give play to the important supplementary role of institution care.First,we must innovate the operation and management methods of rural institution care for the aged,gradually introduce market mechanisms and activate the vitality of the institution care.Then,the service objects of institution care must be clearly identified.The service objects of the institution care should be the elderly groups in plight such as disabled,retarded,senior,seriously ill,low-income,and poor ones.Meeting the needs of these specific elderly groups will be the key to the survival of the elderly nursing institutions in the future.In addition,the urgent needs of rural elderly should be considered to innovate the model of rural institution care.

4.Rural elderly service system combined with medical care

The medical-nursing combined care,one of the important components of the rural elderly care service system,reflects the urgent demands of rural elderly for medical service.However,the medical-nursing combined care is generally not considered to be an independent model of elderly care.As a product of implementing healthy aging,the combined model often develops together with institution care for the aged.Such a combination provides a way of elderly support in which the elderly get medical services such as health examination,rehabilitation care,health education in addition to the basic care.〔12〕As the elderly’s demand for such services like rehabilitation care has increased,some hospital institutions,elderly nursing institutions and social services,in order to increase their core competitiveness and meet the demand of the elderly for medical care,have begun to explore the practice model of medical care suitable for their own development.This model has various forms,including establishing nursing institutions for the aged within the hospital (support from the hospital),setting up hospitals in elderly nursing institutions (the medical care from nursing institutions),and mutual assistance between medical institutions and elderly nursing institutions (combination of the elderly care with medical care),which provides the experience enlightenment and reference for China to explore and develop the medical-nursing combined care.However,the medical-nursing combined care requires dual investment of elderly resources and medical resources,which will often increase the burden on the elderly nursing institutions,and also bring certain economic pressure to the elderly.Specifically,when the medical-nursing combined care is popularized in rural area,it has encountered difficulties such as poor medical service,lack of sharing of medical information,shortage of medical staff,high service fees,and insufficient government subsidies.Although such practice does not go well,its great advantages can meet the urgent needs of the rural elderly.So this practice should receive more support and help.When popularizing the medical-nursing combined care in rural areas,the government should make continuous exploration and innovation in establishing a long-term care insurance system,broadening long-term financing channels,cultivating talents for this activity,and optimizing the mechanism of the elderly care combined medical care.

5.Rural elderly care service system localized with diversified forms for targeted groups according to different realities

The construction of rural elderly care service should be “based on family supporting,supported by community mutual assistance care,supplemented by institution care and combined with medical care”,which is an objective requirement of the actual rural environment and an inevitable choice for the development of elderly care in China’s central and western rural areas over a long time.In addition to the above four basic forms of elderly care service,there are another three points to be paid attention to when constructing rural elderly care service system:

Firstly,the supply form of elderly care service should be diverse.With the rapid development of urbanization and information technology,the demand and supply of elderly care service in rural areas are significantly different from traditional rural elderly care service,and the form of elderly care service should be increasingly diversified and modernized.With the urban elderly care service development as a reference,we can expect that in the future,the rural elderly care service will become increasingly diversified and modernized.The space distance between parents and children may continue to increase,while the space-time distance may be shortened.For example,children working in other places can keep close contact with their parents through information tools such as mobile phones and WeChat,and can monitor their parents’ physical conditions in real time through family doctor software,which shows tremendous change in children supporting means.In order to adapt to this historical trend,the construction of the rural elderly care service system should be compatible and open from the beginning.We should actively advocate and introduce modern technologies,and continuously enrich and innovate the modern elderly care service forms.

Secondly,the service objects of various elderly care models should be distinguished.There should be clear direction for the construction of rural elderly care service system in the future,which means that various elderly care service models should be oriented to specific elderly groups and provide professional and high-level elderly care service.From the perspective of the three rural elderly care service models,family supporting should serve the elderly who have self-care ability,or whose children are taking care of them by their side;community mutual assistance care should serve the elderly who have self-care ability,but their children are not taking care of them by their side;institutions care should serve the poor elderly group who are unable to take care of themselves and whose children have no time to take care of them for a long time.In addition,different types of elderly nursing institutions,at various levels and providing different services,should be established according to the different characteristics of different elderly groups.

Thirdly,the reform and reconstruction of the rural elderly care service system should conform to the local practice environment instead of rigidly copying the elderly care service model in the urban or developed areas.Due to the differences in economic level between urban and rural areas and differences between rural areas,it is difficult to achieve unification and consistency when popularizing the model of elderly care service.Only by combining with the local rural practice and exerting the local people’s ability and wisdom,the demand of the rural elderly for diversified care service can be met to the largest extent.