Worldwide aging is considerable and in particular in Europe and Asia. The percentage of the population of Germany above 65 reached 22% in 2020, that of France reached 21%, and that of China reached 14%. Although China’s percentage is lower, the challenge is more severe, given the size of the country with an elder population over the age of 65 reaching 191 million ^[1]. Moreover, China’s aging process is very fast with an expected pronounced acceleration between 2015 and 2040. By 2050, about 26% of China’s total population will be 65 or older, and 8% will reach 80 years and older ^[2]. At the same time, until the 1980s, institutional elder care was virtually unknown in China, and the few facilities that existed were social welfare institutions run by the government ^[3]. China had to build an elder care system basically from scratch in only a few decades. Nonetheless, studies about population aging and elder policies tend to focus mainly on Western countries ^[4].

Kudo et al. ^[5] argue that while developing nations face socioeconomic challenges similar to those of developed nations, they moreover face the pressure to meet the basic needs of the growing aging population. China was confronted with the task of building not only an elderly care infrastructure but also a pension and social insurance system while facing a shrinking labor force in the near future. Massive migration (1979–2015) to urban areas, especially of young people, combined with the one-child policy, left many older individuals in rural communities without traditional family support (filial piety) [6,7,8,9]^[6][7][8][9]. This problem required institutional interventions. To meet these challenges, the Chinese government launched a first perennial policy for the aging undertaking in 1994. This initial seven-year plan was followed with subsequent five-year policy plans. Many countries introduced policies and innovative strategies to deal with aging ^[8]. The paradigms of active and healthy aging emerged worldwide as a policy response to reduce the growing financial impact of health care and to contain the increasing overall challenges of population aging ^[10]. It is generally recognized that older individuals can contribute and provide meaningful economic and social benefits, especially when active and healthy ^[11]. Moreover, to prevent social isolation and loneliness and related health care issues, it is vital for elder individuals to continue to be active members of society.

Notwithstanding the fact that socioeconomic changes and subsequent policy responses vary across continents, almost all countries are facing similar social and political pressures that influence both the demand and supply of elderly care ^[12]. Today, there is a tendency of policies to shift from government-centered to more neighborhood and home-centered approaches in several countries ^[13]. For the setup of the elderly care system, China could follow the example of Western models or choose the Asian approach of community care or, alternatively, create its own model ^[14].

2. Overview of the Five Chinese Elderly Policy Plans from 1994 until 2020

WResearchers identified three distinct periods of elderly care development. The first development period 1994–2001 includes the Seven-Year Plan and the 10th Five-Year Plan. Economic development was still considered to be the solution to the improvement of the aging population conditions. Focus was on the construction of elderly homes. The 11th Five-Year Plan, 2006–2010, represents the second development period. This FYP shows a deeper-going social inclination with the aim of constructing a harmonious society. In 2009, a major nation-wide health care reform was inaugurated. This second period is a transitional period. The third period, 2011–2020, comprises the 12th and 13th Five-Year Plans. In the 12th FYP, China’s central government officially proclaims a new elderly care infrastructure: ‘elderly home care as foundation; community elderly care as support; and state institutional care as supplement’. This period enhances the traditional virtue of filial piety. The switch from elderly homes in the first period to home care more recently resembles the development of Western elderly care. In several European countries, the focus on home care was intensified in the 2000s ^[12].

3. Elderly Care Service Infrastructure

At the launch of the first perennial elderly policy plan in 1994, the nursing system in China was rudimentary. Delivery of medical care services relies heavily on the public hospital sector. Public hospitals represented 34.7% of all hospitals and 72.5% of all beds in 2019 [28]^[15]. Because government funding for health dramatically decreased since the 1980s, hospitals must find their own budgets to cover expenses. Health providers started to overprescribe drugs and treatments ^[6]. Out-of-pocket payments soared, and patients avoided specialized health care [29]^[16]. Rural elderly individuals were affected the most by these changes [30]^[17]. The major health care reform in 2009 started to improve the overall system [31]^[18]. A decade later, important progress was the decrease in out-of-pocket health expenses from 59% in 2000 to 29% in 2017 [32]^[19]. In the policies from 1994 to 2005, the government paid more attention to institutional homes [33]^[20]. The goal of 30 beds per 1000 elderly individuals was set within the 12th Five-Year Policy Plan (12th FYP hereafter). A report issued by the Peking Union Medical College states almost 1.6 million beds remained vacant by the end of 2016 [34]^[21]. Apparently, the new facilities are often too remote from the original living community. Luo and Zhan (2011) argue that older adults, when not fully cared for by their children, suffer from personal stigmatization [35]^[22]. The 13th Five-Year Policy Plan (13th FYP hereafter) urges the multiplication of rehabilitation departments, hospice care institutions and geriatric training and research. To ensure funding, the government encouraged in 2016 the private sector to run 50% of China’s elderly care facilities and beds [36]^[23]. China targeted employing 6 million nurses in elderly care establishments by 2020, a growth with approximately 1.5 million. The 11th Five-Year Policy Plan (11th FYP hereafter) encourages the training of community nurses and General Practitioners (GPs). The shortage of GPs remains a key issue. In 2019, the country counted a total of 365,082 GPs, representing 2.6 GPs per 10,000 people [37]^[24]. The government started to train 500,000 additional GPs in 2018 to reach a rate of 5 GPs per 10,000 residents [38]^[25]. People still prefer to go to hospitals even for minor consultations, which leads to long waiting times in hospitals. China now focuses on the support of information technology and has started the establishment of 68 internet hospitals in 2017 [29]^[16]. Internet platforms and remote monitoring at the community and home care levels have been set up in major cities [39]^[26]. China’s overall elderly care infrastructure is developing rather fast, yet manpower resources are only slowly increasing. Since the efforts of the state to provide elderly care homes have not succeeded, more attention is given to community and home care. The introduction of internet information platforms and virtual nursing can attenuate the shortage problem of nurses and GPs.

4. Community Care Involvement

Community care covers three main functions: community day care, home-based care support as well as cultural and sport activities. Community involvement is encouraged in all policy plans. To develop capacity, the central government issues a range of policy measures to attract and stimulate service providers to enter the elderly care market [40]^[27]. First, in 2018, the government abolished the mandatory need for a license to establish a community care institution. Elderly care policy plans request local governments to set up facilities for senior education and leisure (parks, green spaces, sports, and recreational sites) to support healthy aging. In 2006, the central government announced the national availability of 30,000 sport grounds and over 670,000 recreational amenities for the older population [41]^[28]. Cultural activities are highly recommended in policies. Today, China has approximately 70,000 senior colleges providing courses for over 8 million participants [42]^[29]. To implement the facilities, local governments face significant financial investments. Decentralized economic development has given rise to socioeconomic disparities. While provincial capitals or large cities possess many facilities, infrastructure remains scarce in underprivileged rural areas [4,39]^[4][26]. More recently, efforts have been made to develop community services in rural areas. Communities play an important role in the organization of outdoor and indoor health, leisure facilities as well as in the delivery of home care for the elderly.

5. Home-Based Care

China’s elderly care is often described as a ‘9073’: 90% of elderly are cared for by family, 7% receive community care and 3% live in a nursing home [40]^[27]. According to Chinese tradition, adult children are expected to take care of their aging parents. Traditionally, only childless and impoverished elder individuals entered public homes [33]^[20] and Chinese elderly can therefore feel a prejudice toward entering a nursing home. More recently, the policies are stimulating home care. The 12th FYP announces the new mode: home-based care represents the cornerstone, community care is the backing and institutions are supplements. The 12th and 13th FYPs moreover incite family members to live close to their parents and promote intergenerational cohabitation. Long-term care becomes crucial when older individuals encounter difficulties in conducting their daily activities due to disability [43]^[30]. The family doctor contracting service implemented in 2016 further stimulates integrated care for the home-based older population, which is one of the priority groups to be served by family doctors [44]^[31]. Recognizing that technological progress can facilitate home care, the government is promoting smart digital technology [40]^[27]. Virtual nursing systems, robotics, monitoring and call-service platforms are more widely introduced [39]^[26]. From 2015 to 2020, the central government allocated 5 billion yuan (approximately USD 743 million) to encourage new pilot programs of home-based elderly care services to be provided by communities in 203 cities [45]^[32]. China’s elderly individuals prefer home-based care and are assisted by community services when needed. Over the past decade, home care has become a priority in the policies, and China focuses on the development of smart home care technology.

6. Filial Piety

Throughout history, Chinese people have carried on the tradition of family support and respect for older people [46]^[33]. In 1996, China enacted the Elder Rights and Protection Law to mandate that adult children take on a moral obligation for their parents’ care, including the financial responsibility to provide for their medical needs and decent housing [47]^[34]. While material support matters, respect and affection are more highly valued [48,49,50]^[35][36][37]. The Chinese family is generally considered as the minimum social unit, not the individual [46]^[33]. Filial piety affirms the norms within the family and provides ethical foundations for the social order. Children’s ‘filial demonstration’ toward parents is socially judged as honorable [49,51]^[36][38]. The 12th FYP encourages traditional values, and states that outstanding filial piety behavior should be rewarded. Filial piety belongs to the core doctrine of the Confucian teachings [47]^[34], and it is important to remind that the 12th FYP was published after the reestablishment of Confucian teachings by China’s government in 2007. This policy advocates mutual affection as well as a warm and harmonious family atmosphere. The 13th FYP stipulates that elderly care must be ‘incorporated into the social morality and family virtues to create civilized communities’. The 12th and 13th FYPs request adult children to assume their filial piety commitment. In contrast to Western cultures, the identity of a ‘person’ is traditionally not rights-oriented but duty-oriented [52]^[39]. However, the effects of the one-child policy (abolished in 2016), demographic changes and the growing participation of Chinese women in the labor market have weakened the traditional caregiving structure [53]^[40]. To restore China’s demography, couples are now allowed to have a third child [54]^[41]. Parent–child interrelationships are slowly becoming more egalitarian. Children often engage in far-reaching careers or even going abroad ^[9], which implies living far away from their parents. Gui and Koropeckyj-Cox (2016) [55]^[42] point out that trust in filial piety nevertheless remains strong in people’s lives, especially among older individuals. China’s elderly population is greatly dependent on informal care provided by family members. The efforts of the state over the past years to reinforce traditional family values appear to have consolidated the virtue of filial piety.

7. Active and Healthy Aging: ‘To Add Life to the Years That Have Been Added to Life’ (United Nations 1999)

Good health and longevity is one of the most respectful greetings one can convey to a Chinese adult [56]^[43]. The first policies emphasize active aging. The ‘young and healthy elderly’ are encouraged to participate in social development (Seven-Year Policy Plan, 1994). This approach can be explained by the fact that in the mid-1990s, competitive pressure pushed state-owned enterprises to lay off workers. Men were often laid off at the age of approximately 50 and women 40. Over 30 million of these workers were laid off [57]^[44]. The policies show concern for elderly and the urge to enrich their spiritual and cultural lives. Spiritual well-being is highly cherished in traditional Chinese culture [58]^[45]. The policy plans promote self-reliance. Elderly are urged to participate in social events and to volunteer and engage in economic activities, i.e., to set up their own businesses (13th FYP). The importance of physical exercises for the elderly is mentioned repeatedly. Over 50% of the elderly should be engaging in physical fitness (12th FYP). In Western countries, active and successful aging is associated with the ability to live independently. The Chinese ‘cultivating and nurturing of the self’ is not associated with this individualistic approach of the West but with an interdependent self, which is determined by one’s place in society and family structure. The willingness of families to care for the elderly is perceived as a sign of successful aging ^[3]. Healthy aging appears in the 12th and 13th FYPs. Following the international trend, China published the blueprint of Healthy Aging in 2016 [59]^[46], placing it in the Confucian tradition: to cultivate the moral self and to conserve one’s vital powers. ‘Healthy aging’ is not merely intended to provide older people with a happy lifetime; the individual health care responsibility is related to the intention of civic duty that urges individuals to stay healthy and avoid becoming the state’s burden [51]^[38].

8. Elderly Care Industry

The elderly care industry is developing. The 11th FYP advises ‘guiding the elderly to rational consumption’ and simultaneously ‘cultivating the consumer market for senior products and services’. The 13th FYP announces that the elderly service market will be ‘fully liberalized and market players will be supported’. The 12th and 13th FYPs encourage the establishment of call-service platforms and virtual nursing systems. The new generation of digital technology, cloud computing, artificial intelligence and robotics is developing fast. In 2015, the central government launched the Guiding Opinions of Actively Promoting Internet + Actions, which was followed by ‘The Action Plan for the Development of Smart Health and the Elder Care Industry (2017–2020)’ in 2017. A total of 99 companies were selected in the course of 2017 and 2018 to enter the smart technology market with a focus on home and community care services [36]^[23]. China’s ‘Big Health Industry’ includes health and medical care sectors. The elderly care sector comprises 33% of the total market size, covering a broad range of products, such as care services, facilities, health equipment, smart technology, insurance and tourism. The elderly care industry also comprises real estate. Parallel to the modest set-up of elder homes, luxury elder real estate is developing for the well-off in numerous urban areas [60]^[47]. The market for China’s elder care products is growing fast. In 2017, the market value was estimated at approximately US$0.79 billion, which accounts for a 12% increase over 2016. The prediction for the 2030 amount is US$15.22 billion [36]^[23]. Commercial health and LTC insurance are part of the market. Over 2400 insurance products are available for people aged 65 and above [61]^[48], and approximately 59 million elderly are participating in 2020 in the commercial health insurance supplement [61]^[48]. For long-term care (LTC), the Chinese government is guiding approximately 49 pilots in 2020 [61]^[48] with virtual platforms for common elderly care services. Since 2011, policies have mentioned the need for LTC. The LTC insurance market is dominated by state enterprises and private conglomerates [62]^[49]. Small enterprises cannot easily survive, since the sector requires material long-term investments offering a low (but steady) return [63]^[50]. Major Chinese enterprises are expanding internationally, such as the conglomerate China Oceanwide, which acquired Genworth in 2016, the largest LTC insurance company in the United States [62]^[49]. China’s young LCT insurance branch can benefit from these experiences. Products specializing in the older population are becoming a major industry.