Aging Welfare and Social Policy: China and the Nordic Countries in Comparative Perspective [1st ed.] 978-3-030-10894-6;978-3-030-10895-3

Table of contents :
Front Matter ....Pages i-xii
Front Matter ....Pages 1-1
Welfare States with Nordic Characteristics (Stein Kuhnle)....Pages 3-14
Building a Welfare System with Chinese Characteristics: From a Residual Type to Moderate Universalism (Yi Pan)....Pages 15-29
Evolution and Construction of China’s Social Protection System: A Discussion from the Perspective of Shared Development (Chunguang Wang)....Pages 31-51
Front Matter ....Pages 53-53
“Aging in Community”: Historical and Comparative Study of Aging Welfare and Social Policy (Sheying Chen, Jason L. Powell)....Pages 55-69
Front Matter ....Pages 71-71
Sweden: Aging Welfare and Social Policy in the Twenty-First Century (Sven E. O. Hort)....Pages 73-90
Looking for the Easy Way Out: Demographic Panic and the Twists and Turns of Long-Term Care Policy in Finland (Teppo Kröger)....Pages 91-104
Policy Responses to Aging: Care Services for the Elderly in Norway (Rune Ervik)....Pages 105-124
Is Finland Connected for e-Health and e-Welfare? (Minna Zechner)....Pages 125-138
Front Matter ....Pages 139-139
Social Construction, System Defects, and System Quality of a Welfare Policy and Regulation Framework for the Elderly of China (Jitong Liu, Yu Liu)....Pages 141-167
Social Organisations and Old Age Services in Urban Communities in China: Stabilising Networks? (Bingqin Li, Lijie Fang, Jing Wang, Bo Hu)....Pages 169-209
Community Based Social Services for the Elderly in Urban-Rural China: Investigations in Three Provinces (Yi Pan)....Pages 211-231
Appendix: China’s Elderly Care Policy and Its Future Trends (Haijun Cheng)....Pages 233-237
Back Matter ....Pages 239-245

Citation preview

International Perspectives on Aging 20 Series Editors: Jason L. Powell, Sheying Chen

Tian-kui Jing Stein Kuhnle Yi Pan Sheying Chen Editors

Aging Welfare and Social Policy China and the Nordic Countries in Comparative Perspective

International Perspectives on Aging Volume 20

Series Editor: Jason L. Powell Department of Social and Political Science, University of Chester, Chester, UK Sheying Chen Department of Public Administration, Pace University, New York, NY, USA

The study of aging is continuing to increase rapidly across multiple disciplines. This wide-ranging series on International Perspectives on Aging provides readers with much-needed comprehensive texts and critical perspectives on the latest research, policy, and practical developments. Both aging and globalization have become a reality of our times, yet a systematic effort of a global magnitude to address aging is yet to be seen. The series bridges the gaps in the literature and provides cutting-­ edge debate on new and traditional areas of comparative aging, all from an international perspective. More specifically, this book series on International Perspectives on Aging puts the spotlight on international and comparative studies of aging.

More information about this series at http://www.springer.com/series/8818

Tian-kui Jing  •  Stein Kuhnle  •  Yi Pan Sheying Chen Editors

Aging Welfare and Social Policy China and the Nordic Countries in Comparative Perspective

Editors Tian-kui Jing Institute of Sociology of Chinese Academy of Social Sciences Beijing, China

Stein Kuhnle Department of Comparative Politics University of Bergen Bergen, Norway

Yi Pan Institute of Sociology Chinese Academy of Social Sciences Beijing, China

Sheying Chen Public Administration/Social Policy Pace University New York, NY, USA Center for Social Work Study Tsinghua University Beijing, China

ISSN 2197-5841     ISSN 2197-585X (electronic) International Perspectives on Aging ISBN 978-3-030-10894-6    ISBN 978-3-030-10895-3 (eBook) https://doi.org/10.1007/978-3-030-10895-3 Library of Congress Control Number: 2019934959 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

The recognition, mutual learning, and comparative study of social welfare between China and Nordic countries, as well as their welfare development experiences, provide an excellent point of view that can open up a broad scope of thinking with great value in both research and academic fields. First of all, both China and Nordic countries have created an extremely valuable welfare construction experience. The Nordic welfare model enjoys a widespread global reputation. It is not only universal but also economically sustainable. These “double-strength” features have withstood a series of tests ranging from the oil crisis of the 1970s to the financial crisis beginning with the twenty-first century. The Nordic model basically provides both political and social stability with a high national happiness index. In particular, its scientifically designed welfare system and its reliable operational mechanism are worthy of in-depth discussions academically. China’s welfare practice has gone through a complicated and arduous exploration process. However, with detours and learning experiences, it has also made remarkable achievements. Especially in the 40 years of reform and opening up, China has established a comprehensive and complete welfare system covering 1.3 billion people. The Chinese system is not only the largest in terms of scale but also the greatest in terms of generality. That is to say, in just a few decades, 800 million Chinese people have come out of poverty. China’s contribution to global poverty reduction has exceeded 70%; that is, China is also the country with the largest poverty population reduction in the world. In addition, it is the first in the world to fulfill the United Nations Millennium Development Goals. By 2020, China will historically eliminate absolute poverty, which will be a great moment in the history of the Chinese nation. This rich experience of the Chinese system is also self-evident. Second, the enormous differences between China and Nordic countries highlight the distinctive characteristics of each welfare system and provide a unique environment for comparative research. With the high levels of income in Nordic countries and the relatively low per capita income in China, in terms of the welfare system design, for example, the payment system, should reflect this difference. Each Nordic country is a nation-state; although China has 56 ethnic groups, there are also obvious differences in the unity and diversity of the system. The Nordic v

vi

Preface

countries do not have much difference between urban and rural living situations and their regional disparities are also more balanced, whereas China has long implemented a dual urban–rural system. Despite efforts to narrow the gap between urban and rural areas in recent years, more time is clearly required to resolve this problem. The regional disparities are caused by a much longer historical process. All these factors have particularly emphasized the tremendous conflicts between universalism and specialization in the welfare system. In comparison, these differences between China and Nordic countries have enabled us to have a much clearer, richer, and deeper understanding of the nature of welfare and its realization. Third, and last, the common pursuit for the values of social welfare by both China and Nordic countries makes it possible for them to reach consensus and consistent conclusions. The Nordic countries have placed social welfare at the forefront with a strong sense of government responsibility and a high degree of identification with citizen recognition, forming a matured welfare culture tradition. In contrast, in China a “Fu” (fortune) culture has existed since ancient times. As early as in the Xia, Yin, and Zhou Dynasties, old-age benefits were already established. “Governing the Country by Filial Piety” was further developed in the Han Dynasty. The central government of the Han Dynasty established an “emperor stick” system for seniors. Since then, for thousands of years, Chinese people have always maintained the tradition of family support and mutual support for the elderly. Nowadays, taking the people’s well-being as the ultimate goal of governance, the Communist Party of China and the Chinese government have endeavored to improve and implement various welfare systems, including social services for the elderly. It can be said that although China and Nordic countries have different national and social environments, as well as public sentiments, their goal of pursuing the happiness of the people is the same. The government and the society share a high degree of consensus. Therefore, mutual learning and mutual recognition are not only necessary but also conscious actions by both parties. Based on these foregoing considerations, the Sino-Nordic Welfare Laboratory in the Chinese Academy of Social Sciences (CASS), under the support and sponsoring of the Institute of Sociology of CASS and Sino-Nordic Welfare Research Network (SNoW), has held the first session of a Sino-Nordic welfare forum with the title of “Ageing Welfare & Social Policy.” This international seminar brought together scholars from China, Nordic countries, the United States, Australia, and other Asian countries from related academic and research areas, and they had a full exchange and discussion on the welfare system, social policy, and especially welfare for aging people between Sino and Nordic countries. This book, a revision and update of the conference papers, is divided into two parts. The first part is a general study of the welfare system of the Nordic welfare states and China. In his article “Welfare States with Nordic Characteristics,” Stein Kuhnle wrote that the characteristics of the Nordic welfare states are precisely as follows: emphasize the public awareness of citizen welfare, the principle of universal population coverage, adherence to social equality, and the normative basis of specific formal and informal mechanisms for formulating social policies and achieving political agreement. In Dr. Yi Pan’s paper, “Building a Welfare System with Chinese Characteristics,” she comprehensively and systematically analyzed the three transition stages of China’s welfare develop-

Preface

vii

ment process and pointed out that the development of China’s social welfare system is moving toward moderate universalism: First, moderate universalism is designed to meet all people’s basic needs, reflecting relative fairness and equality, rather than pursuit of the ultimate average results; second, moderate universalism recognizes that people have different abilities and provides all individuals with fair development opportunities and equal benefits; and third, moderate universalism means that standards and costs are not high, and the development is sustainable. In Mr. Chunguang Wang’s article “Evolution and Construction of China’s Social Protection System: A Discussion from the Perspective of Shared Development,” the main social policies that constitute China’s social protection system are thoroughly dissected from the three levels of legal validity, degree of protection, and sustainability. He also compared the Chinese social protection system with the Japanese and Korean social protection systems, pointing out that although China has built a fairly complete social protection system, there are still problems such as inadequate coordination, weak protection capabilities, a low level of protection, and poor sustainability. The second part is the main body of the book. In this part, numerous articles discussed many aspects of elderly welfare from different perspectives. Among these, the article by Sheying Chen and Jason L.  Powell, “Aging in Community: Historical and Comparative Study of Aging Welfare and Social Policy,” makes an historical comparative study of aging, family, community, and social policy from several aspects of aging welfare. It reveals the theme of the book with a comprehensive understanding. Dr. Pan’s article, “Optimizing and Integrating Urban and Rural Resources and Improving the Comprehensive Community Aged Services System— Study on the Comprehensive Aged Care Service System in Shanghai, Gansu, and Yunnan,” offers actual cases and a practical base for understanding the subject of the book. Other articles introduced and discussed the elderly welfare and care services in Norway (Rune Ervik), Sweden (Sven E.O. Hort), Finland (e.g., Minna Zechner and Teppo Kröger), China (e.g., Haijun Cheng, Jitong Liu, Bingqin Li, Lijie Fang, Jing Wang, and Bo Hu). All the authors are well-known experts in the field. Every paper in this book is informative, analytical, and instructive. I am grateful to the scholars from both Nordic countries and China for writing and publishing this book. These authors contributed their long-term valuable research results to this book. Dr. Yi Pan, a fellow researcher of the Chinese Academy of Social Sciences, has studied in Nordic countries and the United Kingdom with a doctoral degree in social policy. Professor Sheying Chen of China’s Tsinghua University and also Pace University in the United States has long been engaged in cross-national comparative studies on social welfare and social policies. They are all outstanding experts in this field, and have devoted themselves to the writing and publishing of this book. My special thanks also go to Springer International Publishing Company for their support for the comparative study of social welfare in China and Nordic countries! I sincerely welcome your comments and suggestions in the hope that this book will further promote the study of social welfare in the world. Beijing, China

Tian-kui Jing

Contents

Part I Welfare State and Social Policy 1 Welfare States with Nordic Characteristics������������������������������������������    3 Stein Kuhnle 2 Building a Welfare System with Chinese Characteristics: From a Residual Type to Moderate Universalism��������������������������������   15 Yi Pan 3 Evolution and Construction of China’s Social Protection System: A Discussion from the Perspective of Shared Development ��������������������������������������������������������������������������������������������   31 Chunguang Wang Part II Aging Welfare and Social Policy 4 “Aging in Community”: Historical and Comparative Study of Aging Welfare and Social Policy��������������������������������������������������������   55 Sheying Chen and Jason L. Powell Part III Nordic Countries 5 Sweden: Aging Welfare and Social Policy in the Twenty-First Century ����������������������������������������������������������������������������������������������������   73 Sven E. O. Hort 6 Looking for the Easy Way Out: Demographic Panic and the Twists and Turns of Long-Term Care Policy in Finland��������   91 Teppo Kröger 7 Policy Responses to Aging: Care Services for the Elderly in Norway��������������������������������������������������������������������������������������������������  105 Rune Ervik

ix

x

Contents

8 Is Finland Connected for e-Health and e-Welfare?������������������������������  125 Minna Zechner Part IV China 9 Social Construction, System Defects, and System Quality of a Welfare Policy and Regulation Framework for the Elderly of China����������������������������������������������������������������������������������������������������  141 Jitong Liu and Yu Liu 10 Social Organisations and Old Age Services in Urban Communities in China: Stabilising Networks? ������������������������������������  169 Bingqin Li, Lijie Fang, Jing Wang, and Bo Hu 11 Community Based Social Services for the Elderly in Urban-Rural China: Investigations in Three Provinces������������������  211 Yi Pan 12 Appendix: China’s Elderly Care Policy and Its Future Trends����������  233 Haijun Cheng Index������������������������������������������������������������������������������������������������������������������  239

Contributors

Haijun  Cheng  Training Center of Ministry of Civil Affairs, Beijing Social Administration Vocational College, East Beijing, China Sheying  Chen  Public Administration/Social Policy, Pace University, New York, NY, USA Center for Social Work Study, Tsinghua University, Beijing, China Rune Ervik  NORCE Norwegian Research Centre, Department for Social Sciences, Bergen, Norway Lijie Fang  Social Policy Research Centre, Institute of Sociology Chinese Academy of Social Sciences, Beijing, China Sven E. O. Hort  Linnaeus University, Kalmar and Växjö, Sweden Bo Hu  London School of Economics and Political Science, London, UK Tian-kui  Jing  Institute of Sociology of Chinese Academy of Social Sciences, Beijing, China Teppo  Kröger  Department of Social Sciences and Philosophy, University of Jyväskylä, Jyväskylä, Finland Stein Kuhnle  Department of Comparative Politics, University of Bergen, Bergen, Norway Bingqin Li  Social Policy Research Centre, UNSW, Sydney, Australia Jitong  Liu  Department of Health Policy and Management, School of Public Health, Peking University, Haidian District, Beijing, P.R.China Yu Liu  Department of Health Policy and Management, School of Public Health, Peking University, Haidian District, Beijing, P.R.China Yi Pan  Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China

xi

xii

Contributors

Jason  L.  Powell  Department of Social and Political Science, The University of Chester, Chester, UK Chunguang Wang  Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China Jing Wang  Social Policy Research Centre, Institute of Sociology Chinese Academy of Social Sciences, Beijing, China Minna Zechner  University of Lapland, Rovaniemi, Finland

Part I

Welfare State and Social Policy

Chapter 1

Welfare States with Nordic Characteristics Stein Kuhnle

1.1  Introduction: Varieties of Welfare States Welfare states come in different sizes, forms and shapes, thus it is not possible to speak about the welfare state. It is commonly agreed upon that the origins of the Western welfare state date back to the last quarter of the nineteenth century, and are closely associated with major social, economic and political transformations at the time (Castles, Leibfried, Lewis, Obinger, & Pierson, 2010). Great societal transformations of industrialization, rise of capitalism, urbanization and population growth paved way for a new role of the state as to welfare responsibility for its citizens. Traditional forms of welfare provision offered by families, guilds, voluntary organizations and charities, churches and local communities came to be seen by many people in authoritative positions as insufficient welfare providers. The last two decades of the nineteenth century mark the “take-off of the modern welfare state” (Flora & Alber, 1981), and inaugurated the emergence and growth of social insurance-­like policies. The great societal transformations were conducive to a “new thinking” about the social role of the state: Should the state take a more active social role, and if so, in what way? On entering the twentieth century, social policy and welfare emerged to become a crucial issue on the political agenda, first and foremost in Western countries, whether democratic or authoritarian, and already from the beginning significant variations among Western nations could be observed. The foundations for a divide between a social insurance model premised on an application of relatively pure insurance principles (continental Europe) and a social citizenship model premised on universal tax-based provision (Scandinavia, Britain, The paper was originally presented at the International Seminar on Ageing Welfare and Social Policy, 20–21 June 2015, Chinese Academy of Social Sciences, Beijing. S. Kuhnle (*) Department of Comparative Politics, University of Bergen, Bergen, Norway e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_1

3

4

S. Kuhnle

Canada, New Zealand) were, although not necessarily intentionally, established in this early period (Kuhnle & Sander, 2010). Over time, over the last 100 and so years, welfare states have developed along different paths, and ideas and institutions have spread globally, across different systems of governance, different political-economic systems, different cultures with varying traditions of relations and mutual expectations between citizens and the state. Welfare states vary in scope and format, and in political orientations and distributional outcomes (Arts & Gelissen, 2010). Although every state, and every welfare state, from one perspective can be considered unique, it makes sense as many scholars, myself included, have done, particularly over the last 25 years, to identify patterns which makes it meaningful to group countries into different “worlds”, “regimes”, “types” or “models” of welfare states. Consequently, also with such conceptualizations, the aim is to try explain why different kinds of welfare states have developed and explain implications of different kinds of welfare state constructions for distributional outcomes, political cleavage structures, and generally for their social, economic and political effects. Esping-Andersen (1990) built upon earlier attempts (Titmuss, 1974; Wilensky & Lebeaux, 1958) at classifications of welfare states when he published Three Worlds of Welfare Capitalism. His much-quoted book has had a defining influence upon the field of comparative welfare state research since its publication. Esping-Andersen distinguished between the “liberal” welfare regime (e.g. USA); the “corporatist-statist” or “conservative” regime (e.g. Germany) and the “social democratic” welfare regime (e.g. Sweden). In the following, I shall briefly sum up my perspective as to what I consider to be major elements of one such type of welfare state or regime, namely the kind of welfare state which has become known as “the Nordic welfare model”.1 What are the characteristics of this “model”? And can we, as a parallel to the expression “Socialism with Chinese characteristics”, speak of “Welfare states with Nordic characteristics”?

1.2  Major Elements of the Nordic Type of Welfare State2 The notion of a Nordic welfare model predates Esping-Andersen’s typology from 1990, although the concept of a “model” was not often used (but see Erikson, Hansen, Ringen, & Uusitalo, 1987). The origin of such a concept and a specific Nordic experience can be traced to the period between the two world wars in the twentieth century, to the 1930s, when an outside perspective on Scandinavia led the American journalist Marquis Childs to coin the term “middle way” to describe  The label can vary. Sometimes the Nordic experience of welfare state development is referred to as “the Scandinavian welfare model” or “the social-democratic welfare model”, or it is referred to as nation-specific models, e.g. “the Danish-”, “the Norwegian-” or “the Swedish model”. My first publication on “the Scandinavian model” was published (in Norwegian) in 1990 (Kuhnle, 1990). 2  Parts of the text in this section build on Alestalo, Hort, and Kuhnle (2009). 1

1  Welfare States with Nordic Characteristics

5

the Swedish development (Childs, 1936). The “middle way” was one between high degree of unregulated capitalism on the one side and authoritarian/totalitarian systems and ideologies on the other (Nazism in Germany; Communism under Stalin in the Soviet Union). The decade before the outbreak of World War II in Europe is marked by the social democratic parties ascending to political power in the Nordic countries, most particularly in the three Scandinavian countries, Denmark, Norway and Sweden. In the same decade, major agreements between the trade union movements and employers’ associations were made (except in Denmark, where such an agreement was made already in 1899, as the first country in the world), to define rules for the process of negotiating work conditions and wages, and the embryonic development towards the post-war regular contact and cooperation channels between the organizations in the labour market and governments was initiated. This was, and has become, a kind of neo-corporatist system of governance complementing the system of governance manifested through general elections of representatives of various political parties to parliaments, and governments being formed on the basis of parliamentary majorities of general or case-by-case support (in the latter instance if only minority governments can be formed). The notion of a distinctive Nordic type of welfare state has (had) normative connotations, most often of a positive nature, as an example of a model to follow towards a “good society”, understood as generally high level of well-being, little poverty, and egalitarian income distributions, but sometimes also of a negative nature, as something to be avoided, given presumed undesirable economic effects of too much emphasis on public responsibility and equality. The recognized British liberal-conservative weekly magazine The Economist has over a short period of time displayed an ambiguous attitude: in its special annual issue at the end of 2006, it spelled out the scenario or “forecast” for political developments in different parts of the world for the following year. It was said that: “It is widely thought that the Nordic countries have found some magic way of combining high taxes and lavish welfare systems with fast growth and low unemployment…Yet, the belief in a special Nordic model, or “third way”, will crumble further in 2007” (The Economist, December 2006). But, in its regular weekly issue of 2 February 2013, after the most critical years of the financial crisis, a recession and austerity policies in Europe, it presented a cover page and devoted a special section to “The next supermodel: Why the world should look at the Nordic countries” (The Economist, 2 February 2013). So, which perspective is most convincing: that the Nordic model is fading away, or that it is becoming a “supermodel”? Or is the future somewhere between “no model” and “supermodel”? There exist many different conceptions of “the Nordic welfare model”, and some may even claim that “there is no such thing as a Nordic model” (Ringen, 1991), meaning that welfare states do not come as types or models, and that the experience and institutions of each state are unique. Although the conception of models, and a Nordic welfare model being one, is a construction, a simplification of reality, I find it analytically useful to distinguish between “types” or “models” of welfare and relating to various welfare states as proximate empirical examples.

6

S. Kuhnle

Since the 1980s, based on results from a number of comparative studies of welfare states, the concept of a “Nordic” or “Scandinavian model” or “welfare regime type” has successfully entered our vocabulary, whether that of international organizations, that of scholars and that of mass media covering the Nordic countries. As mentioned, for the most part the concept has a positive connotation, but not always, this being dependent upon context, time period and the ideological eyes of the observer. To put it crudely, neo-liberals and old Western marxists seem to share a sceptical view, while social democrats and moderate conservatives and liberals more gladly than most bring out a strongly positive view. In fact, many Nordic social democrats will claim that it is their model, but in a historical perspective that is much too simplistic.3 Within the Nordic countries the notion is generally positively laden to the extent that political parties have competed for the “ownership” of the kind of political system and welfare state that the concept is seen to denote. The concept is broad, vague and ambiguous, but it is a helpful reference for observers of varieties of market-oriented welfare democracies (cf. Leibfried & Mau, 2008). But we can also observe that European welfare states seem to be on a track of mutual learning, in particular in the areas of family and labour market policies (Borrås & Jacobsson, 2004), implying that European welfare state models are becoming more intermixed and less distinct (Cox, 2004; cf. also Abrahamson, 2002). I use the concepts of “Scandinavian” and “Nordic welfare states”, or “Scandinavian” and “Nordic welfare model” interchangeably. All of these concepts are used in the literature. In geographic terms, the “Scandinavian” reference would include the mountainous peninsula of Norway and Sweden, plus Denmark, while “Nordic” includes Finland and Iceland as well. For historical, institutional, cultural and political reasons, since Nordic regional political, institutionalized cooperation have developed since the 1950s, e.g. creation of a passport union, a free Nordic labour market and a “social union”, I think the concepts “Scandinavian” and “Nordic” can be used interchangeably (cf. also Hilson, 2008). In terms of “welfare states” or “welfare models” the five countries, with some exceptions for Iceland, also share a number of characteristics. If we accept the notion of a Nordic welfare model, the analytical findings of a very comprehensive literature can be summarized in three master statements, the Nordic welfare state is about: Stateness; Universality; and Equality. In addition, I think a further element, which goes beyond pure characteristics of the welfare system, must be included in order to understand how the evolution of “the politics of welfare”—how formal and informal systems of governance—has impacted the welfare state and continuous reform efforts and decisions.

 The Swedish Social Democratic Party has, much to the surprise of many Nordic scholars in the field, in fact in 2014 got “The Nordic Model” accepted as their trademark by the Swedish agency for patent and trademark registration (“Patent- och registreringsverket”). The Nordic Council of Ministers has, correctly in my opinion, protested such an attempt at political monopolization of the concept. 3

1  Welfare States with Nordic Characteristics

7

1.3  Stateness The Nordic welfare model is first of all based on an extensive prevalence of the state and the public sector in the welfare arrangements. The stateness of the Scandinavian countries has long historical roots and the relationship between the state and the people can be considered as a close and positive one. The implication is not that the state sends “… rain and sunshine from above” (Marx, 1852/1979, pp. 187–188), but rather that the twentieth century state has not been perceived as a coercive apparatus of oppression in the hands of the ruling classes. It rather has, for most of the time, developed as a peaceful battleground of different classes assuming an important function “as an agency through which society can be reformed” (Korpi, 1978, p. 48). The stateness implies weaker influence of intermediary structures (church, voluntary organizations, etc.), but it includes “relatively strong elements of social citizenship and relatively uniform and integrated institutions” (ibid.).The class compromise [of the 1930s] was an important element in the making of the Scandinavian type of welfare state (Flora, 1986, pp. xvii–xx). The role of the state is seen in extensive public services and public employment and in many taxation-based cash benefit schemes. It should be remembered, however, that social services are mostly organized at the local level by numerous small municipalities that makes the interaction between the decision makers and the people rather intimate and intensive. “The difference between public and private, so crucial in many debates in the Anglo-American countries, was of minor importance in the Scandinavian countries” (Allardt, 1986, p.  111). For example, until recently it has been considered legitimate for the state to collect and publish tax records of individual citizens. It is probably no accident that Sweden and Finland have the oldest population statistics in the world.

1.4  Universalism In the Nordic countries, the principle of universal social rights is extended to the whole population. Services and cash benefits are to a lesser extent than elsewhere targeted towards the have-nots as they are universal in character and also cover the middle- and high-income classes. In short: “All benefit: all are dependent; and all will presumably feel obliged to pay” (Esping-Andersen, 1990, pp. 27–28). The universalistic character of the Nordic welfare state has been traced to “both idealistic and pragmatic ideas promoted and partly implemented” in the making of the early social legislation in the years before and after the turn of the twentieth century. Social security programmes were initiated at the time of the political and economic modernization of the Scandinavian countries and the idea of universalism was at least a latent element of the “nation-building” project. And, secondly, the similar life chances of poor farmers and poor workers contributed to the recognition of similar risks and social rights: Every citizen is potentially exposed to certain risks.

8

S. Kuhnle

Thirdly, especially after the Second World War, there has been a strong tendency to avoid the exclusion of people with poor means in Scandinavia. And finally, there has been a very pragmatic tendency to minimize the administrative costs by favouring universal schemes instead of extensive bureaucratic means-testing (Kildal & Kuhnle, 2005; Kuhnle & Hort, 2004, pp. 9–12). As of the early 1970s all Nordic countries had established universal coverage of old age pensions systems, sickness insurance, medical care, occupational injury insurance, child allowances and parental leave schemes. The unemployment insurance was (and is) in principle universal and compulsory in Norway only, while merely trade union members were covered in the other countries, but all unemployed are entitled to cash benefits within some programme. The same overall institutional pattern has persisted until this day, but continuous reform activity has generally, although with variations among the Nordic countries, led to various modifications in e.g. pension programmes (with a strengthening of the insurance principle) and unemployment insurance, and to more co-­ payment in the health sector. Current developments indicate a move towards a more mixed welfare system, where the role of private pension and health insurance will increase, but more as supplement to public welfare and without jeopardizing the basic idea of universalism.

1.5  Equality The historical inheritance of the Nordic countries is that of fairly small class, income, and gender differences, although the full implementation of gender equality policies, with concomitant norms and popular expectations, came relatively late, in the post-World War II period. The Scandinavian route towards the modern class structure was paved with the strong position of the peasantry, the weakening position of the landlords, and with the peaceful and rather easy access of the working class to the parliamentary system and to labour market negotiations. This inheritance is seen in small income differences and in the almost non-existence of poverty (Fritzell & Lundberg, 2005, pp.  164–185; Ringen & Uusitalo, 1992, pp.  69–91). The combination of progressive income tax systems and universal, and relatively generous, social security and welfare systems has implied redistribution, little poverty (in relative and absolute terms) and egalitarian income distributions. According to recent OECD statistics, all five Nordic countries are among the 8–10 nations of the world with the most equal distribution of disposable household income,4 with Denmark, Norway and Sweden among the top five. Moreover, Scandinavia is famous for her—comparatively speaking—small gender differences. When the municipalities share a great part of the responsibilities for childcare and care of the old and disabled and when the employment rates of women are high, the gender differences play a lesser role in the Nordic countries than in other parts of the  This statement on most equal “in the world” is most likely justified although the OECD statistics only cover its 34 member countries. 4

1  Welfare States with Nordic Characteristics

9

advanced world (cf. Lewis, 1992; Sainsbury, 1999). Keeping in mind the relatively high level of welfare benefits, the extensive public services, and women’s relatively good position in the labour market it has been, somewhat ironically, pointed out that Scandinavian men are “emancipated from the tyranny of the labour market and Scandinavian women are emancipated from the tyranny of the family” (Alestalo & Flora, 1994, pp. 54–55).

1.6  Actual Forms of Governance The Nordic model is normally identified by reference to characteristics of welfare state institutions (stateness and universalism) and welfare policy outcomes (equality). But it seems appropriate to add a fourth component, namely forms of governance—which refers to the way in—or process through—which political decisions are made. In this respect, the decade of the 1930s represented a political watershed in all Nordic countries with national class compromises between industrial and agricultural/primary sector interests, and between labour and capital through the major trade union federations and employers’ associations. These compromises also came to be reflected at the parliamentary and governmental level, with political compromises reached across parties representing various class or economic interests. From the late 1920s, Denmark was ahead acting as a policy role-model not least for Swedish social reformers (Nystrøm, 1989). Nevertheless, the title of book mentioned, by the American journalist Marquis Childs, on Sweden: The Middle Way (1936) captures the path-breaking change of Nordic politics in the 1930s. The politics of the 1930s came to be formative for the kind of Nordic (welfare) model existing today, though these achievements at the time remained precarious and, from a broader European perspective, peripheral. A wide concept of the Nordic model must include aspects of the actual forms of governance in the Nordic countries, the evolution of a specific pattern for conflict resolution and creation of policy legitimacy as basis for political decision-making and authoritative decisions. This pattern has developed over a long period of time and is characterized by the active involvement by and participation in various, often institutionalized, ways of civil society organizations in political processes before decisions are formally made by parliaments and governments, most particularly pronounced through triangular relationships between government, trade unions, employers’ associations or similar organizations in, for instance, the agricultural sector. This system of governance may be labelled “consensual governance”. The Nordic countries are small and unitary, which make decision-making easier than in big and/or federal states. The case of Finland’s development towards a consensual democracy has been more dramatic than in the other cases: it is a long distance in politics and time from the Civil War of 1918 to the strongest example of consensus-building in peacetime Nordic politics represented by the “Rainbow Coalition” government—comprising the parties of the communists, social democrats, liberals and conservatives—of the early 1990s, which was established to set the Finnish economy and welfare state right after the

10

S. Kuhnle

dramatic economic downturn partly caused by the break-down of the Soviet Union and an abrupt loss of substantial foreign trade. “Consensual democracies” is a term that generally fits developments since the mid-1930s, and particularly since 1945, also reflected in several book titles (Elder, Thomas, & Arter, 1988; Rustow, 1955). Consensus-making has become an important element of Nordic politics partly for the simple fact that coalition governments are the rule—especially in Denmark and Finland—, and—in particular for Denmark, Norway and Sweden—the prevalence of minority coalition governments. Denmark is a world champion when it comes to scope of minority governments. The Nordic tradition of what can be called “negative parliamentarism”—that the government does not have to be positively or constructively based on a majority in the parliament nor to be installed by a parliamentary majority—has logically appealed to the art of making political compromises: sustainable political decisions can hardly be made without parties in advance consulting each other, creating mutual trust, and without government parties consulting opposition parties at any time. The consensual style of Nordic politics and the experience of long-term multiparty parliamentary and/or governmental responsibilities is one reason why it makes more sense to use the geographical adjective “Nordic” rather than  – as many of my social science colleagues do  – use the narrower, political-­ideological adjective “social democratic” when naming the “model”. A partial exception to this picture is Sweden, where the Social Democrats throughout the twentieth century had a more dominant position, and where debates on principles of social reforms at times appear to have been more polarized (Lindbom & Rothstein, 2004).

1.7  Nordic Cooperation A note must also be made on the development of Nordic cooperation in the field of social policy—and the consolidation of a Nordic identity—as factors being conducive to the development of the Nordic (welfare) model. The development of formal inter-Scandinavian cooperation between parliamentarians started already in 1907. In this field of policy, the first of many regular joint Scandinavian top political-­ administrative meetings took place in Copenhagen in 1919. Finland and Iceland joined these meetings in the 1920s, and according to an overview provided by Petersen (2006) there were over the years 14 such Nordic meetings of social policymakers before the Nordic convention on social security was decided in 1955, after the establishment of the Nordic Council in 1952, and which Finland was “allowed” (by the Soviet Union) to join in 1955. These developments inaugurated sustained Nordic cooperation to this day across many public policy areas. A common, comparative and comparable, Nordic social statistics was established in 1946. Not least the fact that the Nordic countries pioneered transnational regional cooperation after World War II has been conducive to the maturing of a concept of a “Nordic model”. And this cooperation developed in spite of different foreign policy orientations— differences mainly due to the war experience and geopolitical realities during the

1  Welfare States with Nordic Characteristics

11

Cold War—ranging from NATO-membership in the Western Nordic countries (Denmark, Iceland, Norway) over Swedish neutrality to a friendship pact between Finland and the Soviet Union in the Eastern part of the Far North. It says something about the historical strength of Nordic identity and the strength of relation-building developed both at governmental and non-governmental levels over a long period of time prior to World War II that Nordic political cooperation could be strongly institutionalized in the early developing years of divisive Cold War mentality and international relations. After the end of the Soviet Empire, the countries still relate differently to both NATO and the EU (Only Denmark, Finland and Sweden are members, and only Finland has introduced the Euro), but a common Nordic identity prevails and is given outlet both in common Nordic and in other international fora. Nordic unity on issues of human rights, welfare and politics is often expressed through UN and other international organizations. The period ever since the early 1930s can, in terms of welfare state development in the Nordic countries, be characterized as one of domestic consensus-building and common Nordic identity-­ building. These two elements are crucial pillars of the conception of a Nordic model.

1.8  Social and Political Stability A last reflection should be added, namely that the particular Nordic combination of stateness, universalism, equality, forms of governance, and let me also include cross-national cooperation, taken as a whole, distinguishes the Nordic welfare states from other Western welfare states. This combination of political organization, policies, institutions, principles, and social and economic outcomes, has—in comparison with other Western countries and types of welfare states—not been a brake on long-term economic development and growth (as measured by growth of GDP and GDP per capita), and it has been conducive to high levels of trust in government institutions, including trust in an efficient and effective public administration, and high levels of social and political stability. Comprehensive, egalitarian and relatively generous welfare states can go hand-in-hand with efficient and productive market economies.

1.9  Challenges and Current Reform Trends The Nordic countries are traditionally open economies and thus not alien to economic globalization. Some would say that this is one of the reasons why “strong” welfare states have developed in this region of Europe (Katzenstein, 1985). Globalization and internationalization of the economy has increased during the last 25 years, and made national economies in general more vulnerable to what happens in the international economy, as the recent global financial crisis has shown. The Nordic countries are of course also more than before exposed to international

12

S. Kuhnle

economic development, but the existence of well-developed welfare states, with the characteristics referred to, may in fact be a comparative advantage if a crisis looms. The welfare state can serve as a buffer towards the risk of sudden increases in poverty and income and social inequality, and the political tensions likely to otherwise follow from such social upheavals. Other challenges for the Nordic—as other welfare states—are the changing composition of the population given an ageing of the population and persistent lower-­ than-­population-reproduction fertility rates. But demographic changes seem to be less challenging in the Nordic countries than in many other nations, in Europa and East Asia. Migration patterns are a bigger “unknown”, and large-scale immigration can, if it occurs, imply a great challenge for the welfare state as such, and for integration and social cohesion, but it is a question of what kind of immigration (labour immigrants; skilled or non-skilled; asylum-seekers; immigration for permanent residency or for short-term labour?; from where?, etc.) when one shall assess the impact or significance for the organization, financing and provisions of the welfare state. Trends towards more privatization of welfare (pensions, health, social care) as a supplement (or alternative) to public welfare provision can imply a development towards mixed welfare and a social division of welfare in the future, which may most likely have implications for both “the politics of welfare” and the format of state welfare state institutions (less universal? less generous?). On the other hand, development towards increasing inequality is not popular among the majority of voters and government and parties may be forced to devise policies to modify inequalities. Europeanization of social policy represents another challenge—for better or worse, also for political decision-making since it may mean less national autonomy in the field of social policy. General reform tendencies in Europe over the last two decades are evident in the field of pensions, health policy and labour market reforms, with more emphasis on individual responsibility for future pensions; more co-payment in medical or health care; more targeting of welfare provision and more emphasis on the so-called “work line”—activation policy with efforts to get unemployed and partially disabled persons back into the labour market. On the other hand, “family policies” making it possible to reconcile work and family (paid parental leave; kindergartens) have expanded in most European countries—and beyond Europe. The welfare state in the Nordic countries and elsewhere has not been substantially de-constructed, but rather re-constructed with a variety of combinations of benefit cuts (“less of the same”) and stricter eligibility criteria for receiving benefits (e.g. unemployment benefits; increase of retirement age). The Nordic welfare model is not static. It is continuously reforming, adapting to changing demographic, economic and political challenges, but still retaining the fundamental characteristics as outlined above. Nordic welfare states have had their ups and downs during the last four to five decades, but have in a long-term perspective appeared to be fairly robust and viable. The Nordic countries did not deconstruct their welfare states, or their public sectors, or their taxation basis in the heyday of neo-liberalism and the “Washington consensus”. There exists a politically strong

1  Welfare States with Nordic Characteristics

13

normative commitment to the welfare state and a high degree of consensus on its desirability among main actors. There exists a comparatively speaking high citizen trust in government institutions which reinforces the legitimacy of the welfare state construction.

References Abrahamson, P. (2002). The welfare modelling business. Social Policy & Administration, 33(4), 394–415. Alestalo, M., & Flora, P. (1994). Scandinavia: Welfare states in the periphery—Peripheral welfare states. In M. Alestalo, E. Allardt, A. Rychard, & W. Wesolowski (Eds.), The transformation of Europe. Social conditions and consequences (pp. 53–73). Warsaw: IFiS Publishers. Alestalo, M., Hort, S. E. O., & Kuhnle, S. (2009). The Nordic model: Conditions, origins, outcomes and lessons. Hertie School of Governance, Working Papers No. 41. Allardt, E. (1986). The civic conception of the welfare state. In R. Rose & R. Shiratori (Eds.), The welfare state east and west. Oxford: Oxford University Press. Arts, W. A., & Gelissen, J. (2010). Models of the welfare state (Chapter 39). In F. G. Castles et al. (Eds.), The Oxford handbook of the welfare state. Oxford: OUP. Borrås, S., & Jacobsson, K. (2004). The open method of co-ordination and new governance in the EU. Journal of European Public Policy, 11(2), 85–202. Castles, F., Leibfried, S., Lewis, J., Obinger, H., & Pierson, C. (2010). Introduction (Chapter 1). In F. G. Castles et al. (Eds.), The Oxford handbook of the welfare state. Oxford: OUP. Childs, M. (1936). Sweden: The middle way. New Haven: Yale University Press. Cox, R. (2004). The path-dependency of an idea: Why Scandinavian welfare states remain distinct. Social Policy and Administration, 38(2), 204–219. Elder, N., Thomas, A., & Arter, D. (1988). The consensual democracies: The government and politics of the Scandinavian states. London: Blackwell. Erikson, R., Hansen, E. J., Ringen, S., & Uusitalo, H. (Eds.). (1987). The Scandinavian model. Welfare states and welfare research. New York/London: M.E. Sharpe. Esping-Andersen, G. (1990). The three worlds of welfare capitalism. Princeton, NJ: Princeton University Press. Flora, P. (1986). Growth to limits. The Western European welfare states since World War II. Vol 1: Sweden, Norway, Finland, Denmark; Vol. 2: Germany, United Kingdom, Ireland, Italy; Vol. 4: Appendix (synopses, bibliographies, tables). Berlin/New York: Walter de Gruyter. Flora, P., & Alber, J.  (1981). Modernization, democratization, and the development of welfare states in Western Europe. In P. Flora & A. J. Heidenheimer (Eds.), The development of welfare states in Europe and America. New Brunswick/London: Transaction Books. Fritzell, J., & Lundberg, O. (2005). Fighting inequalities in health and income: One important road to welfare and social development. In O. Kangas & J. Palme (Eds.), Social policy and economic development in the Nordic countries. London: Palgrave Macmillan. Hilson, M. (2008). The Nordic model: Scandinavia since 1945. London: Reaktion Books. Katzenstein, P. J. (1985). Small states in world markets: Industrial policy in Europe. Itacha, NY: Cornell University Press. Kildal, N., & Kuhnle, S. (2005). The Nordic welfare model and the idea of universalism. In N. Kildal & S. Kuhnle (Eds.), Normative foundations of the welfare state: The Nordic experience. London: Routledge. Korpi, W. (1978). The working class in welfare capitalism. Work, unions and politics in Sweden. London/Henley/Boston: Routledge & Kegan Paul. Kuhnle, S. (1990). Den skandinaviske velferdsmodell: Skandinavisk? Velferd? Modell? In A. R. Hovdum, S. Kuhnle, & L. Stokke (Eds.), Visjoner om velferdssamfunnet. Bergen: Alma Mater.

14

S. Kuhnle

Kuhnle, S., & Hort, S. E. O. (2004). The developmental welfare state in Scandinavia. Lessons for the developing world. United Nations Research Institute for Social Development, Social Policy and Development. Programme Paper Number 17. Kuhnle, S., & Sander, A. (2010). The emergence of the Western welfare state (Chapter 5). In F. G. Castles et al. (Eds.), The Oxford handbook of the welfare state. Oxford: OUP. Lewis, J.  (1992). Gender and the development of welfare regimes. Journal of European Social Policy, 2(3), 159–173. Lindbom, A., & Rothstein, B. (2004). The mysterious survival of the Swedish welfare state. Paper presented at the American Political Science Association, Chicago September 2–5th. Leibfried, S. & Mau, S. (2008). Introduction. Welfare States: Construction, Deconstruction, Reconstruction. In S. Leibfried & S. Mau (Eds.), Welfare States: Construction, Deconstruction, Reconstruction. Vol. 1: Analytical Approaches. Cheltenham: Edward Elgar: pp. xi-lxiv. Marx, K. (1979). The Eighteenth Brumaire of Louis Bonaparte. In K. Marx & F. Engels (Eds.), Collected works (Vol. 2, pp. 99–197). Moscow: Progress Publishers. (Original work published 1852). Nystrøm, P. (1989). Välfärdsstatens styrningsmekanismer. In Historia och biografi. Lund: Arkiv. Petersen, K. (2006). Constructing Nordic welfare: Nordic social political cooperation 1919-1955. In N. F. Christiansen, K. Petersen, N. Edling, & P. Haave (Eds.), The Nordic model of welfare: A historical reappraisal (pp. 67–98). Copenhagen: Museum Tusculanum Press. Ringen, S. (1991). Do welfare state come in types. In P. Saunders & D. Encel (Eds.), Social policy in Australia: Options for the 1990s. University of New South Wales: Social Policy Research Centre, Reports and Proceedings, No. 96. Ringen, S., & Uusitalo, H. (1992). Income distribution and redistribution in the Nordic welfare states. In J. E. Kolberg (Ed.), The study of welfare regimes. New York/London: M-E. Sharpe. Rustow, D. (1955). The politics of compromise. Princeton, NJ: Princeton University Press. Sainsbury, D. (1999). Gender and welfare state regimes. Oxford: Oxford University Press. The Economist. (2006). The world in 2007 (21st ed.). London: The Economist. The Economist. (2013, February 2). Titmuss, R. M. (1974). Social policy. London: Allen & Unwin. Wilensky, H., & Lebeaux, C. N. (1958). Industrial society and social welfare. New York: Russel Sage Foundation.

Chapter 2

Building a Welfare System with Chinese Characteristics: From a Residual Type to Moderate Universalism Yi Pan

2.1  Introduction In 2017, the 19th National Congress of the Communist Party of China (CPC) stated that the main contradiction of China’s society has changed as socialism with Chinese characteristics entered a new era: the contradiction between the growing needs of the people for a better life and unbalanced and inadequate development. Here, a better life can be explained as well-being, and resolving the contradictions between growing needs and inequality and inadequacy can be understood as relying on the construction of a welfare system. Well-being is the goal of all people’s lives, and the social welfare system is the condition and design to ensure its realization. Under the new situation, the Chinese welfare system needs to be repositioned: a residual welfare system with unbalanced and inadequate development needs to be rebuilt as a welfare system with the principle of moderate universalism.

2.2  T  he Formation, Problems, and Nature of the Residual Welfare System 2.2.1  A  Review of the Formation of the Residual Type of Welfare System in China The development of China’s welfare system has undergone three stages: creation, reform (coexistence of destruction and innovation), and re-structuring. Looking back on the course of the construction of China’s welfare system in the past 70 years, Y. Pan (*) Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_2

15

16

Y. Pan

its development has undergone several twists and turns. The welfare system has developed from the time of state-planned economy domination, to a period of the state emphasizing an economic reform to be market oriented, and then the government put forward the construction of the welfare system with moderate universalism. The reform toward a market economy caused changes in the welfare system. A welfare system under the socialist planned economic system that was created in the early days of the People’s Republic of China, with the characteristics of low levels and wide coverage, has been transformed into a social security system with obvious features of a residual type, with only some of the people possessing it, and partial protection measures. After 1949, with the creation of the People’s Republic of China (PRC), the Chinese socialist welfare system was established, which was based on the principle of planned economy. In the urban welfare system, the state took the responsibility of the policy and budget (making regulations and provision of financial support), and the work units were responsible for the administration of welfare relief and services (organization and operation). In urban areas, all the welfare benefits depended on employment. The welfare items included healthcare, medical services, education, pensions, work-related injuries, housing policies, heating subsidies, transportation subsidies, and other benefits for women and infants. Because the work unit provided many benefits, the urban welfare system called the work unit as a small society. Social assistance in urban areas also included various welfare institutions to take care of such special groups as “San Wu” (the ‘three no’s:’ people who have no work ability, no source of livelihood, and no family support), who were accepted into the social welfare institution. The rural welfare policy is based on land guarantee, implementing social assistance (including natural disaster relief and poverty assistance), a basic compulsory education system, a five-guarantee system (that is, providing food, clothing, housing, healthcare, and funeral services for elderly people who have no family), a cooperative medical system, and collective support under a collective economic system. The rural welfare pattern, called collective welfare, emphasizes mutual help and other informal support, such as family, relatives, friends, or neighbors. The welfare system is under a dual social–economic system. By guaranteeing a relative high living standard for urban residents, by transferring abundant products from rural areas into city and rural areas with the limitation of formal welfare provision, the state accomplished its industrial primitive accumulation during the first decade of the establishment of the PRC, particularly during 1953–1957, to establish a foundation of industrialism. Although the development of an industry system leads to inequality between rural and urban areas, the foundation of the welfare regime in China was built in this period, based on the socialist justice principle and the guarantee of basic life requirements. This is the first time in the history of China that the state has established a welfare system for all the people. In the primary accumulation period, the welfare system is established on the premise of the priority development of industrial production; although it is based on the dual structure in urban and rural areas, its purpose is to cover the basic needs of all the people in all aspects.

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

17

Since the 1970s, after the beginning of economic reform, the government has tried to develop a more effective social security system suitable for the market economy. The social policy of China is beginning to serve economic policy, which is also deeply influenced by the transition of the western welfare state. During the 1970s, in Europe, the Labour Party had transformed into the New Labour, and laissez-faire capitalism was dominant. The Western countries were in “transition from industrial capitalism to financial capitalism (neoliberalism)” (Taylor, 2017). The international society advocated a reform of welfare privatization, scaling back the government’s social welfare spending and supply. During this period, China has advocated welfare individual responsibility and emphasized the welfare system’s marketization principle and the socialization of social welfare. The welfare system of the city based on the work unit collapsed, and the work unit, which used to be called the small society, has become the pure enterprise production unit. The social security system in the city includes various insurances such as the pension, medical, industrial injury, unemployment, and other social insurances. Rural collective welfare has declined with the disintegration of the people’s commune and the collective economy. As Anthony Saich, a professor at Harvard University in the United States, has assessed the reform of the Chinese welfare system at this time: “The responsibility for the provision of services in the welfare system has shifted from government, work units or village collectives of rural areas to local governments, families and religions, even market-oriented organizations” (2012). The result of welfare reform in Western countries is a rise in social exclusion and poverty, and “increasing inequality in income, health care and opportunities of life within and between countries” (Taylor, 2017). In contrast to the trend of neoliberalism, in China the relevant departments of the state explore the establishment of a rural social security system, including rural old-age insurance and disaster relief insurance, and have started a large range of poverty relief and disaster relief measures. By 2017, 800 million Chinese people got out of poverty. The welfare regime in this period is a social security system with social relief and social insurance characteristics. Since 2003, China’s welfare system has started to be reconstructed under the guidance of “people-oriented and building a harmonious society.” In 2003, the third plenary session of the 16th Central Committee of the CPC of China puts forward the scientific development idea of “people-oriented and a comprehensive sustainable development.” The fourth plenary session of the 16th Central Committee of the CPC puts forward the concept of “building a harmonious socialist society.” in 2007, the 17th National Congress of the CPC calls for “accelerating social construction and paying attention to the living standards of the people.” It is clear that the key issue of “building a harmonious socialist society” is that “all citizens have the rights to receive education, remuneration, employment, medical care and housing.” Under this stated guiding ideology, the speed of the construction of a social security system in China has quickened, and development of the welfare system under the new situation is beginning. Social assistance programs have been expanded and improved. Since 2003, China’s social assistance system has introduced new items, including housing,

18

Y. Pan

medical, and educational relief policies. In 2016, a total of 14.799 million people in China received the subsidies of the Minimum Living Security for Urban Residents, 45.765 million people received the subsidies of the Minimum Living Security for Rural Residents, and 4.969 million rural people received rural special hardship support. The coverage of the population by social insurances has expanded. The social insurance system is composed of “five social insurances and one housing fund,” which has been established and developed rapidly. In 2016, 378.62 million urban employees and 508.47 million urban and rural residents participated in the basic oldage insurance. But in 2002, only 82 million people were covered by basic old-­age insurance. In 2016, 748.39 million people were enrolled in basic medical insurance, compared with 100 million in 2002. In 2016, 180.89 million people were covered by unemployment insurance, compared with 4.4 million in 2002. The coverage of work injury insurance reached 218.87 million people in 2016, compared with 45.75 million in 2002. Maternity insurance covered 184.43 million people in 2016, compared to 35 million in 2002 (National Bureau of Statistics, 2016) (Fig. 2.1). Public expenditure on social welfare continues to grow. In 2007, expenditure for education accounted for 2.9% of the gross domestic product (GDP) of the year, and in 2016 it was 3.77%; public expenditure on medical services was 0.8% in 2007, and 1.77% in 2016; public expenditure for social security and employment accounted for 0.2% in 2007, and in 2016 it was 2.9%; housing accounted for 0.8% of GDP in 2011, and was 0.9% in 2016; public service spending was 2.3% of GDP in 2011; and urban and rural community construction accounted for 2.5% of GDP in 2016.

Five insurances (2002-2016) Unit: ten thousand people 2002

2016

88709 74839

18089 8200

10000 440

old age

medical

unemployment

21887 4575 work-related injury

18443 3500 maternity

Fig. 2.1  Coverage expansion of social insurances in China (unit: 10,000 people)

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

19

At present, the welfare system has become involved in social insurance, social relief, special care for the families of revolutionary martyrs and servicemen, social services, compulsory education, medical assistance, housing assistance and charity, and many other aspects of the people’s livelihood. China has formed a social security system with social insurance and social assistance as the core and income support as the main means of guarantee. Social insurance includes old persons insurance, unemployment insurance, industrial injury insurance, medical insurance, and maternity insurance. Social assistance includes disaster relief, poverty relief, minimum living security, housing assistance, child assistance, educational assistance, medical assistance, and urban vagrants’ and beggars’ assistance to provide cash and material relief. Although China’s welfare system is developing rapidly, it is still a welfare system with residual features (Table  2.1). Residual welfare is “selected,” that is, to provide benefits and services to some people, especially those with special difficulties. Because the relief is mostly for the marginalized population, some scholars call it the “marginal” welfare model (Korpi, 1983, pp. 190–192). The residual welfare system mainly provides support by the family and the market. When the provisions Table 2.1  Chinese social insurance and social assistance system in 2017 Welfare system Social insurance system Pension insurance

Medical insurance

Work-related injury insurance Maternity insurance Unemployment insurance Housing insurance Social assistance system Minimum living security system

Medical assistance system

Vagrants and beggars in urban areas Housing Education

Social policy issued (year) Social insurance law of PRC (2010) Basic pension insurance for urban employees (2005) New rural pension insurance (2009) Social pension insurance for urban citizens (2011) New rural cooperative medical care (2002) Basic medical insurance for urban employees (2005) Basic medical insurance for urban citizens (2007) Urban and rural serious illness insurance system (2012) Regulations for work-related injury insurance (2003) Regulations for urban maternity insurance (1994) Unemployment insurance act (1999) Housing accumulation fund system (1994) Regulations for minimum living security in urban areas (1999) Minimum living security system for rural residents (2007) Rural five-guarantee system (1956, 2006) Nature disaster emergency rescue system (2004) Rural medical help system (2003) Urban medical help system (2005) Relief regulation for urban vagrants and beggars (2003) Assistance for housing (2004) Social assistance for rural poor households (2003) Assistance for education (2004)

20

Y. Pan

of family and market fail, and some individual needs cannot be met effectively, the state’s intervention, such as providing social assistance, fills a remedial role. Because of the development stage of China and the influence of neoliberalism on the construction of welfare system in China, the social welfare system of China has obvious residual characteristics.

2.2.2  The Problems of a Residual Welfare System During the past 40 years, China’s economy has developed rapidly, and in terms of prosperity and development, China has become the second largest economy in the world. This prosperity must be reflected in great improvements in people’s lives, and economic progress is for promoting the lives and social development of the people. However, the economic achievements in China have not been shared by everyone, and the welfare system of China is facing many problems. The first problem is polarization and poverty. At present, the per capita of GDP in China is lower than the international average level; there are still more than 70 million people living in poverty. The Gini coefficient has surpassed the internationally accepted warning line of 0.4 for the income distribution gap since 2000, and since then, hovering around this number, has not shown substantial change (Fig. 2.2). In the 1990s, China implemented a policy enabling some people to get rich first. Therefore, “social policies favor cities, coastal areas and the elite, to leave the vast majority of the rural population and the informal sector self-employed completely on their own,” said Anthony Saich (2012). Social policies have undergone many changes and additions since then, but these changes have not completely reduced the differences between urban and rural areas and the income gap between rich and poor. This disparity causes social stratification, polarization, and inequality, and 0.6

1997-2014 Gini index

0.5 0.479 0.473 0.485 0.487 0.484 0.491 0.49 0.481 0.477 0.474 0.473 0.469

0.4 0.3

0.389 0.371 0.378

0.412 0.403

0.433

0.2 0.1 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Fig. 2.2  Changes in the Gini coefficient of China in 1997–2014. Source: National Bureau of Statistics

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

21

further leads to social division, contradiction, and conflict. For the sake of social harmony, a much more fair and just welfare system is needed. Second, the coverage of social insurance is incomplete, and migrant workers lack social security, which reflects inequality. The “five insurances and one fund” have not fully covered all populations, and the standard and contents of the guarantee are also problematic (see Fig. 2.1). In 2015, the migrant population in China stood at 247 million. For migrant workers only, the insurance coverages of “five insurances and one fund” in 2014 were, respectively, 26.2% for work-related injury insurance, 17.6% for medical insurance, 16.7% for pension insurance, 10.5% for unemployment insurance, 7.8% for maternity insurance, and 5.5% for housing accumulation fund. The rates of all coverages are less than one third (The National Bureau of Statistics, 2014) (A reason of low coverage of insurances is that the most of migrant workers joined the rural social security at homes which is different standards with urban one). The proportion of labor contracts signed with employers is 39.7% (Cai, 2017). Migrant workers are also excluded from basic welfare programs such as schooling for their children in the areas in which they have just settled down. The third problem is social protection for the elderly, women, and children in rural areas. In the development of urbanization, farmers became migrant workers to work in the city, which results the separation of families, leaving a large number of children, women, and the elderly left behind in the countryside. According to the data of the sixth census of China in 2010, it is estimated that 40 million old people, 50 million women, and 61 million children are left behind in the rural areas of China (All-China Women Federation, 2013). In the situation as incomplete families, these people need to accept social service welfare in the aspects of bringing up children, education, physical and mental health. In contrast to urban prosperity, in some rural areas the economic and social life and service provisions have declined, as well as the destruction of the living environment. Fourth, as China enters an aging society, the problem of service guarantee for the elderly population becomes serious. The number of elderly people more than 60  years old reached 200 million in 2003, accounting for 14.9% of the total population, and the number of elderly above the age of 65 had reached 123 million, which is 9.1% of the total population. By 2020, the population of elderly more than 60 years of age will reach 243 million (Ministry of Civil Affairs, 2013). The number of old people aged 80 years and above exceeded 20 million in 2010, and reached 23 million in 2013; by 2050, it will increase to 108 million (China Research Center on Aging, 2014). There are also a large number of old people who are incapacitated physically and mentally, and old parents who lost their only child after carrying out the family plan policy, and old people who live alone, whom are called empty-nest elderly (including those elderly left behind in rural areas). These people need to receive social services, including living support and medical services, as well as health and psychiatric care. And neither the welfare policy nor the delivery of services is completely ready for their needs. Fifth, along with the improvement of people’s living standards, a social service system needs to be established. The social policy of China once catered to the trend of marketization, commercialization, privatization, and the promotion of

22

Y. Pan

individualism driven by the neo-liberalism reform of the Western world, which leads to misunderstanding in the exploration of the social welfare system. Welfare reform in Western countries is based on a solid foundation of the welfare system, but China’s welfare system was not ready when it was impacted. There are still problems regarding housing, healthcare, and education, and people demand improvement in the provision of these services. After people have received satisfactory provision for food and clothing, they have further requirements for medical treatment, education, old-age care, environmental protection, healthcare, and so on, and will anticipate comprehensive and more humanized services. Persons with disabilities need community-based rehabilitation services such as physical and psychological treatment and self-supporting integration into society. Maternal and infant health services are needed for the procreation and health of the population. The labor force needs training services for improving their skills and reemployment. These demands go beyond the vulnerable groups, mostly from the middle class. For instance, care services for infants and the aged are needed by every family. However, many services are not included in the social welfare system, resulting in social problems. The Chinese residual type of welfare system only covers part of the population and some welfare items, which results in problems such as narrow and inadequate coverage and lack of integration between urban and rural areas.

2.3  Establishing a Moderate Universalism Welfare System In 2007, the Ministry of Civil Affairs of China stated “in order to speed up the development of social welfare of China, China will promote the transformation of welfare model from ‘residual type’ to ‘moderate universalism’.” The Ministry of Civil Affairs has described this change: “The first of all is a transformation of service groups, and the serves face all people, not only the elderly and the disabled, but also other people who are in trouble. In addition, focus will be shifted in the supply of service items and service products. Expansion of services to medical care, healthcare, rehabilitation, sports and recreation, and comfort and sustenance, etc., is needed to meet the diverse needs of the population at different levels (Dou, 2007). The principle of moderate universalism of the welfare system in China is explained in greater detail as follows. First, the welfare system covers all Chinese people to resolve the disparity between the people’s growing need for a better life and the unbalanced development of the society. The welfare system in the principle of moderate universalism means to extend coverage from some people to all people. Through the project design of the welfare system, the goals should be integrated step by step into the entire population. The welfare system should cover all citizens both in cities and in the countryside and narrow the gap between urban and rural areas, regions, income, and the rich and poor; social policies should be inclined toward poor areas and make expansion of transfer payment to poor areas; an unified social security system

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

23

should be established that covers the entire population, changes the fragmentation of the policy, and integrates social insurance programs. China’s social security system is in transition toward a moderate universalism welfare system. For example, only urban workers (employees) had a pension in 2005; by 2009, a new type of rural social insurance for the aging population appeared; in 2011, urban residents’ old-­ age insurance was issued. After the basic medical insurance of urban workers in 2005 (a rural cooperative medical system was re-set up in 2002), basic medical insurance was extended to urban residents in 2007. The new measures show that social insurance is also available to other urban and rural residents who lack working experience and income. Second, the welfare system is extended from cash security to social services to address the conflict between the people’s growing needs for a better life and inadequate development as the main contradiction of society. Welfare measure should be extended from welfare in cash form, such as income and different social insurances, to service security. With the arrival of the aging society, the increases in the migrant population, and the changes in family structure, more people and their families need the support of social services. However, the social service system of China is still in the primary stage. China is going to establish a network platform for community services, a home-based, community-support, and institution-­ complementary system for the elderly (Pan, Sui, & Chen, 2017), and it could extend services to all those in need, including the elderly, the disabled, women, and children and adolescents. Social service supply would meet the people’s needs in medical care, health rehabilitation, life care, training and employment, psychological comfort, legal aid, and culture and entertainment, and enable achieving urban–rural equalization of social services. Third, establishment of a comprehensive welfare system means a transition from solving the food and clothing problem to enabling people to possess dignity and a decent life. With social and economic development and the improvement of the people’s living standard, people have a higher demand for a better life. The moderate universalism welfare system is a system that truly embodies the superiority of socialism, and ensures that the people have a higher quality of life and an overall improvement of their well-being. The welfare system should go beyond social assistance, disaster relief, and social insurance, to address the needs of the people for such needs as housing, medical care, education, and old-age services. In accordance with social and economic development, China would explore new areas of social policy, formulating, adjusting, reforming, and innovating social policies to meet the basic needs of the people, to complete the social welfare system and to rationalize it and make it a sustainable development. For example, with China’s “open two-child policy,” it is necessary to maintain the policy of protecting women and infants and to establish a related system of infant and child care and preschool education, to protect the mother’s and child’s rights and interests, especially for women who are willing to bear a second child. In brief, China’s moderate universalism welfare system is comprehensive, which transcends social assistance and social insurance to provide basic guarantees and extensive coverage. As the deployment of the 19th CPC National Congress stated:

24

Y. Pan

Committing to a people-centered approach. We will intensify poverty alleviation, see that all our people have a greater sense of fulfillment as they contribute to and gain from development, and continue to promote well-rounded human development and common prosperity for everyone. As in Xi Jinping’s speech: “We must grasp the most direct and realistic interests of the people, to persist in treating the masses’ matters of concern as our own big affairs, and start with the matters of masses’ concern, so as to seek more benefits for the people’s livelihood, to relieve the worries of people’s livelihood. We will achieve new goals in these aspects: a baby can be raised, a school-age child can have education, workers will have pay, the sick are cured, old people receive care, people have a house, and vulnerable groups have support—to constantly promote social justice and equity, the all-round development of human beings, and provide all the people with common wealth and prosperity” (2017).

2.3.1  The Expansion of Social Expenditure of Social Welfare In 2016, the state budget for social expenditure on various benefits was 13.8% of GDP (Table 2.2) (greater than 7.4% in 2007 and 10.4% in 2011). Compared with European countries, these numbers are not high. At the end of the past century, social expenditure in the OECD accounted for more than 40% of GDP, while EU countries remained at 50% (Ginsburg, 1993, p. 173). The moderate universalism welfare system needs to increase social expenditures, enable people to share the achievement of reform, and spend money on improving the well-being of the people. The report of 19th CPC National Congress states: “We must put the people’s interests above all else, see that the gains of reform and development benefit all our people in a fair way, and strive to achieve shared prosperity for everyone.”

Table 2.2  State budget on social welfare as a proportion of GDP (2016)

Items Education Social security and employment Healthcare and family planning Housing security Urban and rural communities Social service Total amount

Fiscal expenditure (100 million) 28,056 21,548

Accounting of GDP (%) 3.77 2.90

Accounting for fiscal expenditure (%) 14.94 11.47

13,154

1.77

7.00

6682 18,606

0.90 2.50

3.56 9.90

9936 92,972

1.34 13.8

5.29 52.15

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

25

The Chinese government will strengthen the adjustment of taxes to income distribution. National wealth is accumulation through tax revenue: the modern tax system will promote the construction of the social welfare system. “In terms of the distribution of the tax burden, it must be equity, which means that taxes must be linked to the income and property holdings of each taxpayer, at least let the rich to pay more taxes than the poor” (Gao, 2015).

2.3.2  B  uild a State-Led Institutional Welfare System and Improve the Corresponding Laws and Regulations A universalism welfare system means not only coverage, but also state responsibility. It emphasizes the role of the state and requires an overall plan by the state. A state-­oriented welfare system needs to improve the rules and regulations of welfare and to clarify the responsibilities of government departments at all levels. Although the responsibility for welfare links with the family, society, and different sectors, the state has the responsibility to manage and supervise the market and social services and to stipulate that the family and the individual take the primary obligation in the welfare network. The ruling party of China clarified its political proposal in the report of the 19th National Congress of the CPC: “We must ensure the principal status of the people, and adhere to the Party’s commitment to serving the public good and exercising power in the interests of the people.” The Chinese government is duty-bound for improving people’s well-being and must take the initiative to determine how many projects for the people have not been done, and to cause the people to feel that the government is serving the people.

2.3.3  S  trengthen Social Construction and Social Management, and Accomplish the Service Mechanism of the Welfare System The management and construction of the welfare system is a comprehensive systematic project from central to local governments, going on to urban and rural grassroots communities. It is necessary to build social management and social services in grass-roots communities and make the community a basic platform for providing social services. The government should promote the development of social services, mobilize many factors to participate in the cause of social service, and explore the innovation of social policy. It is necessary to develop and improve nongovernmental, nonprofit, and other social organizations and social enterprises, to explore the integration of various types of service institutions and different proportions of service provision, and to produce professional and effective services in accordance

26

Y. Pan

with social attributes and sustainable laws. The elderly, children, women, and disabled people could receive a variety of services at home, and their community can be like their happy home.

2.4  The Characteristics of the Chinese Welfare System Although China’s welfare system is going to be developed as a moderate universalism welfare system, the Chinese system is quite different from that of the Western developed countries and other East Asian countries. The socialist system distinguishes it from the other East Asian countries, and the Eastern cultural traditions are unlike those of the Western countries. The Chinese welfare system has the following theoretical basis and characteristics. First, the feature of the political basis of China’s welfare system is socialism. China’s socialist political system determines that its welfare system is different from that of other countries. The unity of the main position of the people and the fundamental interests of the state is socialism with Chinese characteristics. As a socialist country, China’s principle is common prosperity. The socialist welfare system is to serve the broad masses of the people, take the interests of the people as the starting point, and let the people have the right to work, the right to labor distribution, and the social right to share welfare. The fifth plenary session of the 18th CPC Central Committee reiterated that “the people are the fundamental force in promoting development, and we must adhere to the people-centered thinking of development, and regard enhancing the well-being of the people and promoting human all-round development as the starting point and foothold of development.” “Shared development,” one of the five development concepts, as put forward by the fifth plenary session of the 18th CPC Central Committee, emphasizes concrete measures for common prosperity. In the matching division system of socialism, there should be no excessive consumption, nor contradiction between supply and demand, and no extreme polarization. Xi Jinping said: “Reform is going in the direction of upholding social equity and justice” (Xi Jinping, 2016). Second, the core of China’s social welfare system is the people’s dominant position. The constitution of China is clear: the People’s Republic of China is a socialist country under the people’s democratic dictatorship led by the working class and based on the alliance of workers and peasants. The fifth plenary session of the 18th CPC Central Committee put forward that six principles must be followed: the first one is to adhere to the people’s dominant position. The people are the masters of the country and development is for the people. The development in recent years is somewhat off track, however. The 19th CPC National Congress calls for a return to people-centered development: “Fully implement the people-centered development concept and continuously improve the level of protection and improvement of the people’s livelihood. Seeking happiness for the people is the initial heart of the Chinese Communists. Never forget the original heart, always regard the people’s yearning for a better life as the goal of struggle” (Xi Jinping, 2017).

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

27

Third, the economic basis of the Chinese welfare system: The socialist economic basis has the principle of distribution. The public ownership of the means of production is the foundation, and the wealth created should be transferred and shared among the people. Thus, the income of state-owned assets should be transformed into expenditure on social welfare. At the same time, it is necessary to invest in social services such as education, medical treatment, housing, old-age care, child rearing, and pregnancy and childbearing among women. In the political economics of socialism, the redistribution of the economy is determined by the people’s status as masters of economic production and social life. The principle of fair distribution of socialism is for every citizen to share the fruits of economic development, through tax transfers and planned social expenditure, to translate economic achievements into social development and improvement in livelihood. The welfare system based on national taxation is the distribution system of the state. It guarantees a decent life for every member. The people are not the burden of society, the burden of government finance, the burden of social security, the burden of medical care and old age: they possess social rights of social welfare. Fourth, the cultural factors of Chinese welfare system: The traditional civilization of China laid the core value and practical foundation of China’s welfare system. More than 2000 years ago, China’s ancient saints and sages described the well-off society and the ideal of the Great Harmony, as well as the people-oriented principle. The idea of great harmony expresses a longing for an ideal society, combined of such values as harmony, peace, and cooperation, displaying harmony among people and between humans and nature. The harmonious community includes regarding the whole world as one community, respecting the old and cherishing the young, and filial piety and equality, which are the core societal values constituting the welfare regime. In addition, in China the inner family relationships are close. The family is treated as the minimum social unit in China, rather than the individual. The collectivism culture with strong bonding among families and neighborhoods is inherited as informal support today. The concept “united construction of the family and the state” is a cultural tradition of China. There is historical expectation and tradition for government to fulfill strong responsibilities in China. In ancient times, benevolent government and decision makers were highly advocated. In modern welfare institutions, the responsibility of the state also takes the chief role in policy design and practices. The current government inherits the Chinese tradition and emphasizes the government’s responsibility for improving the welfare of all the citizens. Fifth are modern factors of China’s welfare system under globalization. During the repositioning of the Chinese welfare system, China is learning the management of modern welfare systems in developed countries, including social security, social insurance, the social work operation system, and even a long-term care system. In the process of the peaceful rise of China, China is integrating into the international community and gradually taking an important role. The rise of China is for the happiness of the people and the prosperity of the country. Meanwhile, with the background of globalization, China is continuing to open up. The Chinese government puts forward its wish to build a community of shared future for mankind (Xi, Jinping). It is an internal welfare idea, transferring to international society.

28

Y. Pan

2.5  Conclusion In short, the Chinese social welfare system is being repositioned, transforming from a residual type to a moderate universalism welfare system. This transformation means that the coverage of social security would extend from only some people to all citizens; the extent of service would move from minority vulnerable groups to all the people; would go beyond economic security to provide basic social services to the people who need these—thus extending from basic income security to a decent and dignified life for the people. The changes are intended to bring the fruits of the reform to everyone, to realize sharing for everyone, to embody the people as the main body, and to develop a better life for all the people with common prosperity.

Bibliography

Chinese All-China Women Federation. (2013). A report on the situation of left behind rural children migrating children in urban and rural areas. See Xinhuanet. Retrieved from http://news.xinhuanet.com/politics/2013-05/10/c_115720450.htm Cai, F. (2017, June 23). When the income increases, the redistribution should also increase. WeChat of Shanghai Research Institute. China Research Center on Aging. (2014). A report of aging industry development in China. Social Sciences Literature Publishing House. Retrieved from http://news.xinhuanet.com/ politics/2013-05/10/c_115720450.htm Dou, Y. (2007, October 23). The change of social welfare from residual type to moderate ­universalism. Public Welfare News. Gao, P. (2015, December 12). China must levy inheritance and gift tax as new categories of taxes. China News. Retrieved from http://www.chinanews.com/cj/2015/12-27/7689857.shtml Hill, M. (2003). Understanding social policy. Beijing: The Commercial Press. Ministry of Civil Affairs. (2013). A national conference on the construction of social service system for elderly in Wulanchabu, Inner Mongolia Autonomous region, Aug. 19. Website of the Ministry of Civil Affairs. National Bureau of Statistics. (2016). Statistical bulletin on human resources and social security development, 2016. Pan, Y. (2014). Rural welfare in China. Social Sciences Literature Publishing House. Pan, Y., Sui, Y., & Chen, S. (2017). Building comprehensive social service system for the elderly in the community with Chinese Characteristics. Population and Society, 2, 30–38, 58. Ping, H. (2016). Persist in people as the hosts and the main body, realise the dream of China. The red flag manuscript, 24th issue. Saich, A. (2012). China’s social welfare policy: Towards social citizenship. Journal of Central China Normal University (Humanities and Social Sciences Edition, No. 4). Taylor, I. (2017). Class, culture and inequality in the neoliberal age. Foreign Theories Trend, No. 11.

2  Building a Welfare System with Chinese Characteristics: From a Residual Type…

29

The National Bureau of Statistics. (2014). Statistical Bureau issued a national survey report for migrant workers in 2014. China government network. Retrieved from http://www.gov.cn/xinwen/2015-04/29/content_2854930.htm The National Bureau of Statistics. (2015). Statistics bulletin on the development of health and family planning in China, 2015. The National Bureau of Statistics. (2016). Statistics bulletin of the national economic and social development of People’s Republic of China, 2016. Xi Jinping. (2016, April 20). Reform towards social equity and justice. Official WebChat of Kunlun institute. Xi Jinping. (2017, October 25). Speech at the first plenary session of the 19th Central Committee. Xinhua News Agency. (2007). The proposal of a well-off society in Seventeenth National Congress, 2 November. Xinhuanet. Retrieved from http://www.zj.xinhuanet.com/2007special/2007-11/07/ content_11608188.htm

English Anttonen, A., Häikiö, L., & Stefȧnsson, K. (Eds.). (2012). Welfare state, universalism and diversity. London: Edward Elgar. Bäckman, G. (1991). The creation and development of social welfare in the Nordic countries. Tampere: Tampere University. Commission on Social Justice. (2000). What is social justice? In C. Pierson & F. G. Castles (Eds.), The welfare state reader (pp. 51–62). Cambridge: Polity Press. Ginsburg, N. (1993). Sweden: “The social-democratic case”. In A. Cochrane & J. Clarke (Eds.), Comparing welfare state, Britain in international context. The Open University. Kidal, N., & Kuhnle, S. (2005). The Nordic welfare model and the idea of universalism. In N. Kidal & S. Kuhnle (Eds.), Normative foundations of welfare state: The Nordic experience (pp. 13–33). London: Routledge. Korpi, W. (1983). The democratic class struggle. London: Routledge. Titmuss, R. M. (1958). Essay on ‘the welfare state’. London: Allen & Unwin. Titmuss, R. M. (1968). Commitment to welfare. London: Allen & Unwin. Wilensky, H.  L., & Lebeaux, C.  N. (1958). Industrial society and social welfare. New  York: Russell Sage Foundation.

Chapter 3

Evolution and Construction of China’s Social Protection System: A Discussion from the Perspective of Shared Development Chunguang Wang

How can development fruits benefit the general public? Social protection has proved to be an important means of sharing at home and abroad and by history. Social protection is a social policy system that adapts to industrialization, urbanization, and modernization and has multiple functions including guarding against social risks, adjusting income distribution, and sharing the fruits of the modernization drive. Therefore, countries around the world have attached great importance to social protection system, whose protection capacity, level and functions vary greatly due to the different economic development levels, history, traditions, and cultures of different countries. What is the situation of China’s social protection system? How can it reflect the concept of shared development? This article tries to shed light on the evolution, status quo, development level, and future development of China’s social protection system by discussing the backgrounds, social protection policies, reform in recent years, and comparisons with the social protection systems of Japan and the Republic of Korea.

3.1  Social Risks Facing China Risks that arise in the process of China’s reform and opening up and economic development have propelled the construction of the social protection system. Over the past 30-plus years, China has experienced unprecedented changes. The Chinese population expanded from 962.59 million in 1978 to 1367.82 million in 2014, with net increase of 452.3 million, exceeding the population of the United States and equivalent to the total population of Europe. China’s economic aggregate has maintained two-digit growth, moving from the ninth place in the world to the second. Its C. Wang (*) Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_3

31

32

C. Wang

GDP surged from RMB367.87 billion in 1978 to RMB 41,303.03 billion in 2010 and RMB64,397.4 billion in 2014, an increase of 175 times from 1978 to 2014, or RMB64,029.53 billion, equivalent to USD1 trillion. In the meantime, China has seen great changes in its employment structure. In 1978, 70.53% of the workforce worked in the primary sector, while only 17.29% and 12.18% were employed in the secondary and tertiary sectors. In 2014, the ratios were 29.5%, 29.9%, and 40.6%, with the tertiary sector employing the most people.1 In 1994, the number of people working in the tertiary sector surpassed that of the secondary sector for the first time, but the largest part of the workforce was still concentrated in the primary sector. It was not until 2011 that the tertiary sector finally overtook the primary sector. Although China is known as the world’s manufacturing center, the secondary sector has never taken the top spot among the three sectors in terms of the number of workers. The changes in employment structure occurred after 2010 when China became the world’s second largest economy; in other words, China entered the stage of post-­ industrial society from 2011. In addition, China’s urbanization rate increased from about 19% in 1979 to about 57% currently, and the number of permanent residents in cities has exceeded that in the countryside. Statistically, China has basically achieved urbanization. Behind such tremendous changes are a great many challenges and risks, such as the rapidly widening income disparity, poverty, aging population, environmental degradation, the urbanization of rural-to-urban migrants, rural development, and unprecedented uncertainties brought by globalization. All these are influencing people’s daily life and the country’s sustainable development. The income gap between urban and rural areas has widened over the past decades. In 1978, per capita disposable income of urban households was RMB343.4, 2.57 times per capita net income of rural households (RMB133.4); by 2012, per capita disposable income of urban households increased 71.5 times to RMB24,564.7, while per capita net income of rural households increased 59.34 times to RMB7916.6, suggesting that the urban-rural income ratio had widened to 3.1:1. Though statistics show that the ratio has narrowed to less than 3:1 in recent years, the urban-rural income gap is still significant. Meanwhile, the income growth of both urban and rural residents has been much lower than the GDP growth. Breaking GDP down into corporate income, government revenue, and residents’ personal income, it can be inferred that the first two have increased faster than the last. For example, China’s fiscal revenue increased 103.55 times from RMB113.226 billion in 1978 to RMB11,725.352 billion in 2012. Though it was a little slower than the GDP growth, the growth rate of fiscal revenue far exceeded that of residents’ income. The Gini coefficient, a measure of income inequality, was only 0.288 in 1982; it peaked at 0.485 in 2009, though it edged down to 0.473 in 2013 (see Fig. 3.1). There is no denying that China has made remarkable achievements in poverty alleviation, halving the rural poor population from 150 million in 1984 to 72 million in 2014 (see Fig. 3.2). However, to lift the 72 million people out of poverty is the most challenging in poverty alleviation. The Chinese government is now working towards the  National Bureau of Statistics of China. http://data.stats.gov.cn/easyquery.htm?cn=C01

1

3  Evolution and Construction of China’s Social Protection System: A Discussion…

33

Fig. 3.1  China’s Gini coefficient from 1982 to 2013 (Source: National Bureau of Statistics of China. http://data.stats.gov.cn/easyquery.htm?cn=C01)

Fig. 3.2  Rural poor population and poverty incidence from 1984 to 2014

strategic target to eliminate poverty in the countryside under current standards by 2020. Meanwhile, there are more than 50 million poverty-stricken urban residents. Urban poverty has just emerged in the past more than 30  years because in the planned economy, the employment and daily necessities of urban residents were basically guaranteed by the state though they were not quite wealthy. Poverty is closely related to unemployment and aging. China’s definition of unemployment differs from that of other countries. Due to the longstanding urban-­ rural dual employment policy, farmers with rural hukou are excluded from the employment policy, so farmers without work are not considered as unemployed, but merely referred to as rural surplus labor force. While a large number of farmers have migrated to cities, their unemployment has not been included into the official

34

C. Wang

Fig. 3.3  Urban registered unemployed rate from 1995 to 2014

Fig. 3.4  Urban registered unemployed population from 1995 to 2014

s­ tatistics. Currently, only urban unemployed residents who have registered at human resources and social security departments are covered by the official statistics. Therefore, data released by the National Bureau of Statistics (NBS) are about urban registered unemployed population and unemployment rate. In 1978, there were 5.3 million urban residents registered as unemployed, with a registered unemployment rate of 5.3%; in 1980, the population was 5.415 million, and the registered unemployment rate was 4.9%. At that time, a large number of educated urban young people returned from the countryside to cities, putting a big pressure on the urban job market. Over the past 20 years, China’s urban registered unemployment rate has stayed below 4.3%. It stood at around 3% in the late 1990s, picked up to 4% in 2002, and has remained around 4% since then. Meanwhile, the urban registered unemployed population has been less than ten million (see Figs. 3.3 and 3.4) (see Footnote 1). In China, there are two other terms relevant to unemployment. The first is surveyed unemployment rate, which refers to unemployment rate obtained through sample surveys. The other is de facto unemployed population, which covers not only registered unemployed population and surveyed unemployed population but also people without work yet having not registered as unemployed or covered in surveys. Obviously, de facto unemployed population is larger than that calculated according to other criteria. However, there are still no reliable data on de facto unemployed population. Through field surveys, we find that structural unemployment

3  Evolution and Construction of China’s Social Protection System: A Discussion…

35

is a prominent problem in China. On the one hand, many enterprises find it difficult to recruit workers they need; on the other hand, a large number of people, including some college graduates and migrant workers, are unable to land a job. This is partly because many college graduates reject low-paying, physical jobs that take long hours, and some migrant workers are too old or lack necessary work skills or proper education background. Aging population is another striking problem in the process of China’s social and economic development. The Chinese population is aging at an unprecedented pace compared to that in other developing countries or even advanced countries. The strict family planning policy adopted by China, along with longer life expectancy, thanks to social and economic progress, has contributed to the acceleration of population aging. According to the sixth national census, in 2010, the average life expectancy of Chinese people reached 74.83 years, 3.43 years longer than that in 2000; the life expectancy for men and women was 72.38 years and 77.37 years, an increase of 2.75 years and 4.04 years, respectively, and the life expectancy gap between men and women widened from 3.70 years in 2000 to 4.99 years in 2010. Meanwhile, there were 212 million people aged 60 years and over in 2014, accounting for 15.5% of the total population; in contrast, there were only 63.68 million and 75.1 million aged 65 or above in 1990 and 1995, accounting for 5.57% and 6.2% of the total population. The number of people above 65 years old was 137.55 million in 2014, an increase of 63.66 million and 62.45 million over 1990 and 1995, and this age group made up 10.1% of the total population in 2014, an increase of 4.53% and 3.9% over 1990 and 1995. From 1995 to 2014, the Chinese population grew 12.93% while the over-65 population surged 83.16%, showing that the speed of population aging far exceeded population growth. The most direct effect is that the old-age dependency ratio increased from 8.3% in 1990 and 9.2% in 1995 to 13.7% in 2014, up 5.4 and 4.5 percentage points, respectively (see Footnote 1). In general, China has achieved remarkable social and economic development since the reform and opening up, people’s living standards have improved, their life expectancy has increased significantly, and the middle class has been expanding. However, there are still many social risks, such as the income gap, poverty, de facto unemployment, and population aging. A main approach taken by many countries in the world to address these social risks is the social protection system.

3.2  T  he Evolution and Characteristics of China’s Social Protection System Social protection system is a security net a modern nation puts in place to guard against social risks, ensure social harmony, and strengthen social development capacity. It includes employment system, social security, health protection, and social services. Due to the different history, cultures, socioeconomic conditions and political regimes, social protection systems vary from country to country. In China,

36

C. Wang

the social protection system is not the same in different periods. Before the reform and opening up, China adopted a centrally planned economy and accordingly, it established a unit-based social protection system in urban areas and a collective-­ based social protection system in rural areas. In other words, the social protection system in urban areas was based on work units, which provided social protection for its workers; leaving the work units meant loss of social protection. In rural areas, the social protection system was based on collectives such as production teams, production brigades, and people’s communes, which provided social protection for rural residents, and the limited state-level social protection support was also delivered through these platforms. In this case, urban-rural gaps in the level, extent and resources of social protection were significant in that social protection for urban workers was in fact provided by the state through work units and they were entitled to stable work, free medical services and all kinds of subsidies and aids, while social protection in rural areas was far from sufficient due to the lack of economic resources and rural residents in many places even didn’t have enough food. The reform and opening up from the late 1970s brought about changes to the urban-rural dual social protection system but didn’t wipe it out. The reform and opening up was mainly carried out in the economic domain, which naturally had impacts on the original social protection system. China’s reform started with the rural production and operation mechanism. The reform of the mechanism removed obstacles to the production and employment of farmers, allowing them to have their own land, use their labor and enjoy the fruits of their labor of their own accord and shaking up the foundation of the commune system composed of production teams, production brigades, and people’s communes. As a result, that system fell apart completely in 1984 and the rural social protection system based on it also started to collapse, reviving the tradition of mutual aid within families and between neighbors. Such a reform indeed boosted farmers’ enthusiasm for production, expanded their employment channels, increased their income, and improved their living conditions. However, it also sent a shock wave through the rural social protection system, especially the fields of healthcare services and education. In the era of the planned economy, despite the relatively low level of rural healthcare services, the three-tier healthcare system in rural areas (health centers, clinics, and barefoot doctors at the level of people’s communes, production brigades, and production teams) played a main role in improving the rural medical conditions and ensuring farmers’ health, which even won recognition from renowned economist Amartya Sen and the World Bank. However, due to the rural reform launched in the 1980s, production brigades and production teams could no longer afford the three-­ tier cooperative healthcare system, so rural health centers and clinics were sold and became privately owned for-profit institutions. The high prices put a heavy burden on rural households, and the problems of unaffordable and inadequate medical services were prominent. Different from healthcare services, the state took over the schools once run by rural collectives and was responsible for inputs in rural education and the allocation of teachers. This to some extent promoted the development of rural education. However, due to the insufficient funding from the state, some schools then charged

3  Evolution and Construction of China’s Social Protection System: A Discussion…

37

all sorts of fees from students. In the 1990s, education expenses became the heaviest burden upon rural households. It can be seen that through the rural reform, the state in fact withdrew from rural areas and the collectives existed in name only and were too cash-strapped to provide any social protection. As a result, rural residents were even deprived of the limited social protection provided by collectives before, and without access to social security or social services, they must cope with all problems and risks solely on their own. The social protection system in urban areas also experienced tremendous changes during the reform and opening up, though it was not shaken up completely like that in rural areas. Urban social protection was based on work units. The urban reform first relaxed restrictions on self-employment, increasing job opportunities; then the contractual responsibility system was adopted in department stores, restaurants and relevant sectors, and labor contracts were introduced to enterprises, especially collectively owned enterprises. Meanwhile, the rural reform allowed farmers to have more job options, and the rural labor force started to seek job opportunities outside the agricultural sector. They migrated to cities and coastal regions from the early 1980s, creating a unique wave of “migrant workers” in the late 1980s. Therefore, apart from workers in government organs, public institutions, and state-owned enterprises, some new groups emerged in urban areas, including the self-employed, migrant workers, and service personnel under contracts. All of them were not entitled to the same social protection policy as workers within the government system, and the social protection system for these groups had not yet been established. In other words, they mainly depended on families, friends, social assistance, and the market mechanism as ways of protection against risks, while the national social protection system excluded them and was trying to expand the role of the market in social protection through reform. In the 1980s and early 1990s, China’s economic reform phased out the “eating from the same big pot” system and lifted restrictions to encourage engagement in economic activities, while withdrawing ineffective systems and practices from social protection to reduce the state’s burden. This was reflected in social spending. According to calculations, China’s total social spending was RMB98.41 billion, RMB106.55 billion, and RMB118.7 billion in 1990, 1991, and 1992, accounting for 30.4%, 29.9%, and 29.2% of government expenditure, not only much lower than that of the United States, European countries, and Japan but also Russia and Central and Eastern European countries (Xin & Meng, 2015). Based on the population at the time, per capita social spending was only RMB86, RMB92, and RMB101, which were less than the monthly disposable income per capita of urban residents but equivalent to one-eighth of the average annual net income of rural residents. Before 1992, China’s social spending didn’t cover medical insurance for urban residents, work injury insurance, and maternity insurance, which were not introduced until 1993; about half of the social spending was used for education, and one-third for healthcare services. In 1993, expenditures on medical insurance for urban residents, work injury insurance, and maternity insurance were RMB130 million, RMB40 million, and RMB50 million, respectively (see Footnote 1), making up a very small part of the social spending. However, they indicated that the country

38

C. Wang

started to construct a new social protection system. The differences between the new system and the previous system based on work units and rural collectives lie in that: first, the new system defined the rights and obligations of individuals, and stipulated that individuals shall contribute to social security; second, it acknowledged the role of the market in social protection, while the previous system neglected the market’s role in employment and social insurance; third, it clarified the new functions and roles of the state and the new relations with the market, individuals, and society, and made it clear that the state shall neither take care of everything nor back off completely. In the 1990s, the new social protection system was still in its infancy and hence far from perfect. The direction was still unclear, the level of protection was low, the capacity of protection was weak, and the relevant systems and policies needed to be improved. The new social protection system was in fact a response to social problems. At the time, China was grappling with three social problems. The first was the reform of state-owned enterprises. In preparation for its accession to the WTO in 2001, China launched a massive reform of state-owned enterprises, leading to more than 40 million lay-offs. Their re-employment, training and life after losing their jobs became an urgent issue. Therefore, the country rolled out re-employment, training, unemployment, healthcare, and other policies, and the social insurance system was introduced at this time. The second was the exponential growth of migrant workers in the 1990s. With China’s rapid economic growth and process in urbanization, rural labor forces swarmed into cities to work in industrial companies or service sector. While their income increased, they faced a lot of risks, among which the greatest risks were work injury and wage arrears, and a long-term risk was pension. Conflicts caused by work injury and wage arrears became a common social problem, posing a threat to social stability. Third, taxation put a heavy burden on farmers due to the taxation system reform. In 1994, China reformed the tax distribution system, allowing the central government to take a big part of tax revenue. Governments at county and township levels could only get a very small share of tax revenue, which was barely sufficient to fund their operation. Therefore, they charged all kinds of additional fees from farmers, and education expenses alone accounted for 17.05% of farmers’ income (Wang, 2007). Many farmers were forced to leave their hometown to work or do businesses, and those staying at home were unhappy with the taxes and fees levied on them. Consequently, the tension between the masses and cadres was building, and conflicts were not rare. These three problems reshaped the relations between the state, individuals and enterprises, requiring the state to consider how to balance the relations to stimulate the development vitality of individuals and enterprises and protect their rights and interests to prevent social problems and conflicts that would undermine social harmony and stability. Thus, it was imperative to put in place the social protection system. However, the new social protection system stayed at a low level and was undergoing the trial-and-error process in the 1990s, unable to well meet the social protection needs. The low level was reflected at least in two aspects. First, although the construction of the social insurance system was under way, social spending just accounted for about 30% of public expenditure and saw no considerable increase. Second, the social protection system excluded rural residents who constituted a

3  Evolution and Construction of China’s Social Protection System: A Discussion…

39

majority of the Chinese population; though the social protection system attempted to include the rural migrant population, local governments had little motivation or few resources to provide social protection for the migrant population while they were struggling to address urban unemployment. “Trial and error” means that some policies lacked consistent, expectable and specific provisions and some were even revoked because of directional errors. A case in point was the commercial old-age insurance the state was promoting in the countryside but didn’t provide any funding support. Such an insurance system failed partly because of rural people’s low awareness of and lack of trust in commercial insurance. They were unwilling to pay for such insurance and doubted whether they could really benefit from it after they retired. Although the system turned out a failure, it provided lessons for the new-­ type old-age insurance system in rural areas launched in 2009. It was not until 2003 that the government started to truly promote the construction of the new social protection system. Some researchers discuss the construction of China’s social protection system from the perspectives of state will, policy capacity, and social pressure (Yue & Liu, 2016). Social policy system is an important part of the social protection system. Into the twenty-first century, the Chinese government realized that blindly pursuing economic benefits and ignoring social progress and social protection poses a threat to sustainable development because of the serious social problems, growing social dissatisfaction, and rising risk of social conflicts. In fact, the social problems at the time were legacies of the 1990s. Obviously, efforts in the construction of the social protection system in the 1990s fell short of the expectation of resolving tensions. In 2000, the issues concerning agriculture, rural areas and farmers evoked strong repercussions in the society. In 2003, Sun Zhigang, who graduated from college 2 years ago, was beaten to death in a hospice of Guangzhou because he was unable to prove his identity. This incident pushed the intensity of social problems to a new high. The academic community, along with other sectors of society, appealed that the country should not continue the practices of “economic development taking precedence over social progress.” Against this backdrop, the Chinese government proposed to build a “harmonious society,” opening a new chapter of the new social protection system. Since 2000, China’s social protection system has shown the following trends. First, a security net that ensures subsistence has been constructed, especially policies and systems concerning the basic needs to provide basic social security. China has basically put in place such a social protection system, which includes all kinds of social assistances, grants, social insurance, the housing system, and employment and training system. Second, the bottom line of social equity is ensured by narrowing gaps between urban and rural areas and between people within the government system and those outside. The social protection system now covers rural areas and is lifting the level of social protection for farmers to that for urban residents, though there are still considerable gaps. Efforts are also being made to ensure that people within the government system and those outside have equal access to social protection, despite the longstanding differences in the level of social protection. In short, all citizens are included in the social protection system and entitled to basic rights, meaning that the target the Chinese government refers to as “full coverage” has been achieved and the bottom line of social equity is guaranteed. Third, the

40

C. Wang

u­ rban-­rural gaps, interregional gaps, and gaps among different social groups in the level of social protection are still huge. Currently, the central government bears about 20% of social protection costs, while local governments at provincial, municipal, and county levels put up the lion’s share of funding. As every administrative region has its own policies, the level of social protection varies greatly and crossregional protection faces all kinds of obstacles, which to some extent influences the rights and interests of people moving from one place to another. Although the country has realized the problems of “multi-tier” funding, to construct a unified national social protection system faces great economic and political pressures due to the structural rigidity of social protection. Fourth, the social self-protection system has been improved. Social self-protection refers to mutual assistances and relieves not provided by the state, and especially various forms of social protection provided by social organizations. In China, social self-protection has become an important part of social protection, which is actually a kind of social protection involving the government, companies, the society, and families. Since the beginning of the twenty-­ first century, social self-protection has drawn greater attention from the state and received more and more policy support. Overall, the construction of China’s social protection system has proceeded with the social and economic development over the past 30-plus years to address social problems and social needs. Although the levels and effects vary at different stages, China has initially established a social protection system covering the whole country. This system is still in the making, with a view to reflecting the values of social sharing, social equity, and economic sustainability and ensuring that China has a stable and predictable future.

3.3  Analysis of Main Social Protection Policies This section introduces China’s social protection policies concerning healthcare services, old-age insurance and services, social assistances and grants, labor and employment, education, housing, social services, and social organizations. Table 3.1 outlines some important social protection policies. It can be seen that a majority of social protection policies were adopted after 2003. Almost all of them were introduced and revised after the reform and opening up, whereas only very few were formulated before the 1980s, such as the medical insurance policy for government organs and public institutions.

3.3.1  B  asic Situation and Contents of Social Protection Policies China’s social protection policies basically cover every aspect of social protection. This part looks at the features and contents of main social protection policies of China. The healthcare policies mainly include public health service, medical

3  Evolution and Construction of China’s Social Protection System: A Discussion…

41

insurance, and medical relief assistance policies, which have been implemented across the country and cover different groups. 98.9% of people have medical insurance, and the medical relief system has helped a large number of low-income people, especially households enjoying the minimum living guarantee, to participate in the medical insurance system and pay for medical expenses. These policies to some extent ensure that the medical and health needs of the Chinese people can generally be met. However, the level of healthcare services varies among different regions and different groups, and there are great gaps between urban and rural residents, between workers inside and outside the government system, and between people in large cities and those in small towns. According to our investigations, the problem of inadequate medical services still exists in many economically underdeveloped rural areas, where public health services are simply about establishing health records and measuring blood pressures and services for chronic diseases are basically unavailable due to the lack of skills of medical professionals. Old-age insurance and services are also an important part of social protection. Different from healthcare policies, old-age insurance and services are not targeted at all Chinese people but require particular conditions. China’s pension scheme includes four parts: (1) Basic pension for urban and rural residents provided by the state. All men reaching the age of 60 and women 55 are entitled to the basic pension provided that they have paid the old-age insurance according to regulations. The basic pension is tiny, but can be helpful for some financially troubled elderly people. (2) Compulsory pension, to which employees and their employers both contribute. The self-employed can also pay a lower proportion of compulsory pensions at their own expenses. The minors and retirees don’t need to pay pension fees. (3) Annuity, a kind of supplementary old-age security provided by employers. Currently, very few employers in China provide annuity, and the pension system reform of government departments and public institutions is taking annuity into consideration. (4) Commercial old-age insurance provided by insurance companies. People can choose to purchase such insurance according to their needs, purchasing power and their trust in insurance companies. These four parts are called four pillars of the pension system. We focus on the first three pillars when analyzing social protection policies. In 2015, 858.33 million Chinese people participated in the pension system, accounting for 62.44% of the total population and 110.82% of the workforce (it also covers people who are not in the workforce). 23.16 million employees had enterprise annuity, accounting for 5.89%% of urban employees.2 For most rural and urban residents (urban residents here refer to people who have urban residency but don’t have a work unit or their work unit doesn’t buy a pension for them), the pension scheme only offers a limited level of protection, while families still play a primary role in taking care of the elderly. Unemployment protection and employment protection are closely related. Unemployment protection is targeted at urban employees, and there is basically no unemployment protection in rural areas. People with unemployment insurance  Ministry of Human Resources and Social Security. http://www.mohrss.gov.cn/SYrlzyhshbzb/ zwgk/szrs/sjfx/

2

42

C. Wang

account for 42.88% of the urban workforce, whereas all employees shall participate in the unemployment insurance scheme according to law. This indicates that the unemployment insurance policy has not been implemented effectively. Even fewer people have benefited from unemployment insurance, only accounting for 1.31% of the population participating in the scheme. This is partly because of the low employment rate in China, but the most important reason is the high threshold and complex procedures for claiming unemployment insurance benefits. Therefore, the unemployment insurance fund ranks the first among the five insurance schemes by surplus. Employment protection covers both urban and rural areas, but is not well implemented and underfunded in rural areas. The government’s initiative to ensure that at least one member in every family currently with zero employment secures a stable job is targeted at urban households. Employment services for migrant workers are basically about providing information. Due to limited inputs, short duration and unpractical training contents, employment training for migrant workers organized by the government has failed to win applause and support from migrant workers, of whom many would rather participate in more useful training at their own expenses. According to the Law on Labor Contracts, enterprises must spend 2% of their profits on staff training. In practice, they use most of the funds for training for middle-level employees and above instead of frontline workers. As a result, regular employees in government departments, public institutions, and state-owned enterprises still have stable jobs like “iron bowls,” while contract workers in these organizations are in unstable employment though employment stability is highlighted in the law. Housing protection emerged in China in the beginning of the twenty-first century. Housing protection includes two parts. The first is housing protection for urban households, including low-rent housing and government-subsidized housing. The Chinese government planned to build 30 million government-subsidized apartments during the 12th Five-Year Plan period (2011–2015). By the end of 2013, there were 14.25 million government-subsidized apartments for rent across the country, benefiting 10.57 million households. The targets for the 12th Five-Year Plan period were basically attained. Government-subsidized housing is targeted at the urban population. Though several cities allow migrant workers to apply, the thresholds are too high for most migrant workers. There are striking interregional differences in government-­subsidized housing. In large cities, government-subsidized apartments are in short supply, while in some small cities (especially counties), many government-­subsidized apartments are vacant because on one purchases or rents them. The other part of housing protection is the renovation of dilapidated houses in rural areas. The government provides a subsidy of RMB30,000 to RMB50,000 for each rural dilapidated house, but some rural households still can’t afford the rebuilding, so they have to give up the opportunity. To ensure access to basic education is a responsibility of every nation. China provides 9-year free compulsory education that includes primary school and junior middle school education. The compulsory education policy was introduced in 1986, but it was not fully implemented until 2003. Before 2003, compulsory education was only available in urban areas, while rural households had to pay tuition and

3  Evolution and Construction of China’s Social Protection System: A Discussion…

43

miscellaneous fees for compulsory education. From 2003, the government exempted rural students from tuition and miscellaneous fees for compulsory education, and provided launch subsidies for students from impoverished rural families. Meanwhile, local governments shut down or merged some rural primary schools and junior middle schools in a move to integrate educational resources. As a result, children in remote rural areas had to attend schools located in the center of the town or even the county. Because of the long distance from home, they had to board, or rent houses nearby with their parents or grandparents living with them, which to a large extent increased the education expenses of rural households. Fees for afterschool classes constitute an education-related burden for urban households. Despite the increase in government inputs in education, education expenses make up a large part of household expenditure and continue to grow. Therefore, education has become another burden on Chinese families in addition to housing and medical services. Family and child benefits are an internationally adopted form of social protection. Countries around the world have formulated different policies focusing on different aspects based on their specific situations and objectives. China provides targeted benefits or assistances for needy families and children. According to statistics of the Ministry of Civil Affairs, in 2015, 4.427 million households received temporary benefits, which averaged RMB67.4 each time, and the total expenditure on temporary benefits reached RMB3.84 billion. There were 502,000 orphans, of who 92,000 lived in welfare agencies and 410,000 were raised by relatives or others. In 2015, a total of 22,000 adoption registrations were handled, including 19,000 registrations of adoption by people in mainland China, 179 by people in Hong Kong, Macau, and Taiwan, and 2942 by foreigners.3 China is now conducting investigations on the more than 50 million left-behind children in rural areas and taking measures to protect their right to survival and development. Currently, China’s policy on family and child benefits still needs to be improved, the level of family and child benefits is relatively low, and social engagement is limited.4 Poverty alleviation is the most important means of social protection. Over the past 30-plus years, China has made tremendous achievements in poverty alleviation. However, the problems of poverty remain serious, especially rural poverty against the backdrop of widening income gaps. The three practices of China in poverty alleviation are as follows. First, social policies ensure that basic living needs are met, such as the minimum living allowance policy and other kinds of assistance and relief policies to ensure access to food, medical services, and housing. Second, the government directly invests in development projects, adopts preferential policies to attract enterprises to invest in poverty-stricken areas and promote their development, and provides equal opportunities and platforms for needy households to engage in the development. The Chinese government released the 10-year outline for poverty alleviation and development in rural areas, vowing to lift the more than  Ministry of Civil Affairs. http://www.mca.gov.cn/article/yw/shflhcssy/  Ministry of Human Resources and Social Security. 2015 Statistical Communiqué on the Development of Human Resources and Social Security. http://www.mohrss.gov.cn/SYrlzyhshbzb/ dongtaixinwen/buneiyaowen/201605/t20160530_240967.html 3 4

44

C. Wang

60 million poor people out of poverty by 2020. The five-pronged poverty alleviation program is now under way, with the aim of lifting people out of poverty through industrial development, resettlement, ecological compensation and education development and social security, the last of which serves as the last line of protection for those most in need. Third, the government has put in place the disaster reduction and prevention policy to minimize the loss caused by disasters and help with post-­ disaster reconstruction to keep disaster-stricken regions and people out of poverty. In 2015 alone, the government resettled 6.372 million disaster-stricken victims. The purpose of social services is to ensure social protection is implemented effectively, and to improve the quality of social protection. In recent years, China has given more attention to the role of social services and rolled out policies to encourage the development of social service organizations. For example, it released the Basic Standard for Social Welfare Institutions Taking Care of Children in 2001 and the Basic Standard for Social Welfare Institutions Taking Care of the Elderly in 2008, introduced the policy on the team of social workers in 2006, issued the Ten-­ year Planning for the Development of the Old-age Service System (2011–2020) in 2011, and released the regulations on government purchase of services from social organizations in 2013; the State Council circulated the Guiding Opinions on the Provision of Cost-of-living Allowances for People with Disabilities in Financial Difficulty and Nursing Care Subsidies for People With Severe Disabilities in 2016; and the National People’s Congress (NPC) endorsed the Charity Law in 2016. By the end of 2015, there were 1.765 million social service agencies and facilities with a total of 13.089 million employees and fixed assets of RMB818.31 billion, and the expenditure on social services reached RMB492.64 billion, accounting for 3.3% of total government spending. Social services have received legal support, won social recognition, and gained market space. Nonetheless, the relevant policies still need to be improved, human resources for social services are in short supply, and social service standards and systems need to be refined.

3.3.2  L  evel of Protection and Sustainability of Social Protection Policies This part analyzes the level of protection and sustainability of China’s social protection. The level of protection is reflected in such aspects as the legal effect of policies, inputs, and the interests of the protected, and sustainability is reflected in fairness in social policy, transparency of policy implementation, support for social and economic development, and accessibility. The level of protection can influence sustainability and vice versa. Here, the two dimensions are discussed in terms of legal effects, funding, coverage, government input, and sense of benefit. According to legal effects, China’s social protection policies include three levels. At the highest level are laws, such as the Social Insurance Law, the Law on Labor Contracts, and the Law on Compulsory Education. At the next level are the regulations and outlines issued by the State Council, such as the Regulations on Providing

3  Evolution and Construction of China’s Social Protection System: A Discussion…

45

Assistance to Households Enjoying the Five Guarantees, Regulations on the Administration of Civic Societies, and Regulations on Minimum Allowances for Urban Residents. At the lowest level are departmental rules, opinions, notices, and announcements, and most of them are on trial and need to be refined before they are upgraded to regulations. Regulations feature greater stability and binding effects and may become laws after a period of time. Laws are compulsory and have the highest level of protection, and any revisions to laws must go through relevant procedures. According to funding responsibility and channels, the social protection system falls into four categories. The first category of social protection, such as compulsory education and social assistance, is fully funded by public finance, namely, tax revenue. In the 1980s, although the Law on Compulsory Education had taken effect, the government failed to fulfill its responsibility for compulsory education in rural areas due to the limited public finance. It was not until 2003 that rural students were exempted from tuition and miscellaneous fees for compulsory education. Social assistance has two functions, namely, ensuring the basic subsistence of all citizens and providing necessary assistances for people in need above subsistence level, especially those deprived of basic rights and interests. The second category of social protection is jointly funded by the government, work units (enterprises, government departments, public institutions, etc.), and individuals. China’s social insurance system has basically adopted this funding mode, which is not a fully market-based mode and is also different from the practice of using tax revenue in North Europe. The third category of social protection is funded by work units, such as annuity, but this is not common. The last category is mutual assistances, such as charity and volunteer services. This form of social protection is taking shape in China, and its role has not been brought into full play. It should be noted that as the Chinese government is divided into at least five levels and governments at different levels take different funding responsibilities, the social protection ability of different administrative regions is not the same and social protection in one region may be not compatible with that in another, posing obstacles to interregional flows. Government expenditure on social protection has increased year by year. Due to the differences in statistical methods and indicators, it is difficult to find the same social spending indicators as those in other countries. Here, government expenditure on education, government expenditure on social security and employment, and government expenditure on healthcare are selected to analyze China’s social spending. Though not constituting the entirety of social spending, the three indicators are the most important part of social spending (see Table 3.1). From 2008 to July 2014, social spending was basically on the increase, despite slight fluctuations between 2012 and 2014. Compared to 2008, the proportion of social spending in total government spending in 2014 grew nearly three percentage points. Specifically, the proportion of government expenditure on social security and employment decreased, that of government expenditure on education increased less than one percentage point, and that of government expenditure on healthcare grew nearly two percentage points. However, people’s sense of benefit has not increased with social spending growth. Even in the field of healthcare where government expenditure grew at fastest

5.9053% 31.9318%

32.4058%

8279.9

10.3347%

14,490.54

6.7047%

10,176.81

10.5207%

15,968.85

15.6918%

22,001.76

23,041.71

15.1804%

2013 140,212.1

2014 151,785.6

32.6096%

5.7522%

7245.11

9.9922%

12,585.52

16.8651%

21,242.1

2012 125,953

a

National Bureau of Statistics. http://data.stats.gov.cn/easyquery.htm?cn=C01

Total government spending (RMB100mln) Government expenditure on education (RMB100mln) % of total government spending Government expenditure on social security and employment (RMB100mln) % of total government spending Government expenditure on healthcare (RMB100mln) % of total government spending The three expenditures, % of total government spending 31.1551%

5.8853%

6429.52

10.169%

11,109.4

15.1008%

16,497.33

2011 109,247.8

Table 3.1  Three main social expenditures and their proportion in total government spendinga

29.4688%

5.3455%

4804.18

10.1593%

9130.62

13.964%

12,550.02

2010 89,874.16

28.8839%

5.2349%

3994.19

9.9694%

7606.68

13.6796%

10,437.54

2009 76,299.93

29.6705%

4.4047%

2757.04

10.8707%

6804.29

14.395%

9010.21

2008 62,592.66

46 C. Wang

3  Evolution and Construction of China’s Social Protection System: A Discussion…

47

rate, the problems of unaffordable and inadequate medical services are still prominent and remain unsolved. Education expenses still put a heavy burden on urban and rural households. Currently, education and healthcare are two objects of public dissatisfaction and criticism. In addition, compared to the growth rate of government spending and government revenue, social spending grows at a relatively low pace, and its proportion in government spending is apparently lower than that in OECD countries, and even lower than some underdeveloped countries. The scope and extent of benefit is another perspective for analyzing the social protection system. Although China has put in place a relatively complete social protection system, the extent to which people benefit from it is far lower than that in developed countries. More importantly, there are great differences in the extent of benefit among different socioeconomic strata and social groups. People working within the government system (work units funded by government revenue) enjoy much higher level of social protection than those outside the government system (work units not funded by government revenue, except state-owned enterprises). Take pension for example. Retirees from the government system can get a pension of more than RMB5000 per month, more than twice that of their counterparts outside the government system (about RMB2000); in contrast, the elderly in rural areas can just get dozens of yuan or a little above RMB100 per month. State-owned enterprises provide higher level of social protection for employees than organizations with other forms of ownership. Employees of many state-owned enterprises can get an income several times or even dozens of times that of their counterparts in other organizations. The level of social protection in urban areas and large cities is higher than that in rural areas and that in small and medium-sized cities and towns. As mentioned above, before it was available in rural areas in 2003, free compulsory education had already been provided in urban areas for years; and the educational quality of urban schools is much better than that of rural schools. It was from 2009 that rural residents started to be covered by the old-age insurance system, with a basic pension of RMB55 per month. At present, rural residents in most provinces are entitled to a pension of just a little more than RMB 70. Medical resources and educational resources are concentrated in urban areas. In particular, due to the low level of medical services in village and township clinics, rural residents sometimes have to go to county-level hospitals and above. It should be pointed out that the “broad coverage and low level” of social protection is only applicable to rural residents and some urbanites. For people within the government system, the level of social protection is even higher than that of developed countries in some aspects. Of course, the differences between people within the government system and those outside are narrowing. In brief, main policies comprising the social protection system vary greatly in terms of time of formulation, level of protection, funding, coverage, and stability. The work unit-based social protection system under the planned economy barely existed after the reform and opening up, and most incumbent social protection policies were introduced in the late 1990s, and the new social protection system expanded rapidly in the 10 years of the twenty-first century. Overall, social protection policies were first implemented in urban areas and then extended to rural areas

48

C. Wang

years later, and the level of protection provided by rural policies is far lower than that of urban policies. Medical insurance policies were adopted before social assistance policies, which came earlier than old-age insurance policies. The logic behind this is that individuals or households alone are difficult to cover the high medical expenses, while taking care of the aged remains a responsibility of families in China. Due to the widening income gaps, some low-income households faced various difficulties in life, which made social assistance policies more urgent than pension policies. In the late 2000s, population aging became an increasing prominent issue, driving the country to extend old-age insurance policies from work units within the government system to other organizations and from urban areas to rural areas.

3.4  Discussion The role and future direction of China’s social protection system need future discussions. Generally, whether a social protection system is a success depends on its functions. The 2015 Global AgeWatch Index released by HelpAge International is here used to assess the old-age benefits of China, Japan, and the Republic of Korea. The Index ranks 96 countries by how well their older populations are faring, and consists of four variables: income security, health status, capability, and enabling environment. The indicators of income security include pension income coverage, poverty rate old age, relative welfare of older people, and GNI per capita. The indicators of health status are life expectancy at 60, healthy life expectancy at 60, and relative psychological wellbeing. The indicators of capability include labor market engagement of older people and educational attainment of older people. The indicators of enabling environment are social connections, physical safety, civil freedom, and access to public transport. All these indicators reflect a society’s level of social protection for the elderly. According to the 2015 rankings, China ranked at 52, the Republic of Korea at 60, Japan at 8, Switzerland at 1, and Afghanistan the lowest at 96 overall. It is justifiable that Japan took the top spot among the three countries of East Asia, but it comes as a surprise that China was ranked ahead of the Republic of Korea. According to the explanations of HelpAge International, China outperformed the Republic of Korea in terms of income security and enabling environment. The old-age poverty rate of the Republic of Korea was 48.5%, much higher than the regional average of 12.9%; it also performed badly in physical safety, civil freedom, and social connections of the enabling environment domain (Table 3.2). Although old-age benefits are comprehensive, they are not necessarily able to reflect the status quo of China’s social protection system in an all-round and effective way. In 2003, Japan’s social spending made up 17.7% of its GDP, of which expenditure on pension accounted for 8.2%, expenditure on healthcare for 6.2%, and expenditure on other services for 1.6%. The Republic of Korea spent 5.7% of its GDP on social spending, of which expenditure on pension accounted for 1.3%,

3  Evolution and Construction of China’s Social Protection System: A Discussion…

49

Table 3.2  Global AgeWatch Index of China, Japan, and the Republic of Korea (“1” as the highest)a China Republic of Korea Japan

Income security 75 82 33

Capability 39 26 7

Enabling environment 28 54 21

Health status 58 42 1

http://www.helpage.org/global-agewatch/

a

expenditure on healthcare for 2.9%, and expenditure on other services for 0.4%.5 In 2014, China’s expenditures on education, social security and employment, and healthcare accounted for 1.58%, 2.48%, and 3.57% of its GDP, which together accounted for 7.63% of its GDP, higher than the ratio of the Republic of Korea in 2003, but lower than it if expenditure on education (3.57%) was excluded. However, they were not comparable because of the different statistical methods. Pension is part of social security. In 2014, China’s expenditure on social security and employment just accounted for 2.48% of its GDP, but in 2003, the proportion of expenditure on pension alone in GDP was 8.2% in Japan and 1.3% in the Republic of Korea. China spent 1.58% of is GDP on healthcare in 2014, but the ratio was 2.9% in the Republic of Korea in 2003 and was as high as 6.2% in Japan.6 Despite the different statistical methods, these statistics overall could reflect that the level of social protection of Japan and the Republic of Korea in 2003 was higher than that of China in 2014. The two countries spent more on social protection, and hence their peoples enjoyed higher level of protection. In addition, there are also considerable gaps in social protection system with the Republic of Korea and Japan. Over the past 30-plus years, China’s new social protection system has achieved full coverage and adopted new social protection policies. However, gaps among different regions, groups, and socioeconomic strata are still prominent. These gaps are reflected in three aspects: urban-rural gaps, gaps between people inside and outside the government system, and interregional gaps. In the future, China should not only lift the level of social protection system but also improve the system through reform. The pension system reform is also considering addressing such differences and has proposed the “one unified system and five simultaneous tasks” initiatives. “One unified system” means that government departments and public institutions will have the same basic old-age insurance system as that of enterprises, their employees will also contribute to pensions, and calculation and payment methods for pensions will be also reformed, so as to address the dual system problems. “Five simultaneous tasks” refer to the simultaneous reform in government departments and public institutions, simultaneous establishment of the enterprise annuity and basic old-age insurance systems, simultaneous implementation of the pension system reform and  http://www.oecd.org/social/expenditure.htm  The Social Expenditure database: An Interpretive Guide. SOCX 1980–2003, OECD 2007, (Version: June 2007). 5 6

50

C. Wang

the improvement of the wage system, simultaneous reform of the benefit adjustment mechanism and the calculation and payment methods, and simultaneous implementation of reforms on a national scale. These initiatives focus on addressing the gaps between people within and outside the government system, rather than the urban-­ rural and interregional differences. From the perspective of social reform, China’s reform has not neglected the urban-rural gaps. It has advanced the integration of urban and rural social insurances, and unified the old-age insurance and medical insurance for urban and rural residents. However, such unification has just been achieved within the same region, and more efforts are needed to unify the systems on a national level. Meanwhile, unified administration of social insurance is also expanding. Old-age insurance has now been unified at provincial level, yet medical insurance still at municipal or county level. More efforts are needed to achieve unification on a national scale. The level of social protection varies among different regions. Economically advanced regions generally provide higher level of social protection than that required by the state, while economically underdeveloped regions can just meet the requirements, sometimes even by finding workarounds. For example, Beijing boasts greater economic strength than Hebei and has more money to subsidize the pension contributions of farmers, so farmers in Beijing get much higher basic pensions and old-age allowances than those in Hebei. China is now promoting the development of the social services sector. In August 2014, the State Council released the Opinions on Accelerating the Development of Modern Insurance Services, with the aim of making modern insurance services an effective mechanism for the Chinese society to respond to social and economic risks (Opinions on Accelerating the Development of Modern Insurance Services [EB/ OL], n.d.). In October of the same year, it issued the Opinions on Accelerating the Development of Old-age Services, which explicitly states that the country “encourages the elderly to buy personal insurance products including long-term nursing care insurance… and encourages and guides commercial insurance companies to conduct relevant businesses.” (Opinions on Accelerating the Development of Old-­ age Services [EB/OL], n.d.) However, the institutional impediments in the social services sector have undermined the motivation of social capital for investing in social services and restricted the development of social services. Meanwhile, personnel that meet the requirements of social services are in seriously short supply partly owning to the flawed talent selection criteria, talent development mechanism, and remuneration, evaluation, and service purchase systems, which greatly hinder the development of social services. The largest reform of the social organization mechanism is to lower the threshold, streamline registration procedures and adopt policies to encourage the development of the four types of social organizations. The government is purchasing more and more services from social organizations, which gives an impetus to the rapid development of social organizations. To sum up, China’s social protection system is being improved. On the one hand, efforts are under way to narrow the urban-rural and interregional gaps in social protection and the differences between people within the government system and

3  Evolution and Construction of China’s Social Protection System: A Discussion…

51

those outside. On the other hand, reforms are going on to eliminate policy issues and institutional impediments, put in place new systems and policies that help to improve the social protection system, expand the space and increase opportunities for social forces participating in social protection, strengthen the capability and efficiency of the government, and ensure fairness in social protection. The rapid development and transformation of China’s society and economy also requires the government to accelerate the construction of the social protection system and lift the level of social protection, so as to better guard against social risks, improve the sense of security, happiness, and benefit and the welfare of all Chinese people, and achieve shared development through collaboration.

References Opinions on Accelerating the Development of Modern Insurance Services [EB/OL]. (n.d.). Retrieved from http://www.gov.cn/zhengce/content/2014-08/13/content_8977.htm Opinions on Accelerating the Development of Old-age Services [EB/OL]. (n.d.). Retrieved from http://fss.mca.gov.cn/article/lnrfl/zcfg/201312/20131200560144.shtml Wang, C. (2007). Study on social differentiation in rural China and farmers’ burden (p.  161). Beijing: China Social Sciences Press. Xin, G., & Meng, T. (2015). Growth in social spending and transformation of public finance in China. Social Sciences in Guangdong, (6). Yue, J., & Liu L. (2016). Is China advancing towards a welfare state? Exploration and Free Views, (6).

Part II

Aging Welfare and Social Policy

Chapter 4

“Aging in Community”: Historical and Comparative Study of Aging Welfare and Social Policy Sheying Chen and Jason L. Powell

Abbreviations AIP CAPS CCRC Danwei GPP LSNS LTC n4a NAOHB NORC WHO

Aging/age in place Certified Aging in Place Specialist Continuing Care Retirement Community Workplace (work unit) General public policy Lubben Social Network Scale Long-term care National Association of Area Agencies on Aging National Association of Home Builders Naturally occurring retirement communities World Health Organization

4.1  Introduction Aging in community is nothing new and has always been a major concern in social policy study worldwide albeit in various, sometimes quite different, forms and traditions. A newer term is called AIP. “You’ve probably heard about the concept of ‘Aging In Place,’ adapting homes to support people being able to stay there as they age. We think that’s great, but not nearly enough. We have witnessed the power of ‘Aging In Community’ making a difference in the lives of our friends and The chapter is amended and expanded from an introductory piece for a Special Issue of Ageing International on Aging in Community (Chen, 2012). S. Chen (*) Public Administration/Social Policy, Pace University, New York, NY, USA Center for Social Work Study, Tsinghua University, Beijing, China J. L. Powell Department of Social and Political Science, The University of Chester, Chester, UK © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_4

55

56

S. Chen and J. L. Powell

neighbors, and want to spread it to the world…” (http://www.agingincommunity. com/, retrieved November 20, 2010). Whether or not such a statement is valid by all accounts, it indicates a need to re-examine related concepts, theories, and practices using a historical and comparative perspective in order to achieve and maintain a comprehensive understanding of the changing fields of aging, family, community, and social policy. Nearly three decades ago, having authored China’s first public lecture series on community service to help start a national movement there (Chen, 1988), the first author went to Hong Kong (then a British colony) to immerse in research including the study of aging. Intrigued by the subject of community care that had taken the center stage of social policy debates amid the transition of a troubled welfare state, he decided to further his case study of China by systematically examining and comparing with Western (particularly British) theory, policy, and practice. At that time, “aging in place” was not heeded (if ever heard) in that part of the world.

4.2  Community Care The expansion of community psychiatric services in Britain dates back at least to the 1930s (Killaspy, 2006). The British Royal Commission on the Law Relating to Mental Illness and Deficiency (1957) set a milestone for the official movement toward community care after various acts and reports (e.g., the 1956 Guillebaud Report of an accounting inquiry into the cost of the National Health Service) (Baugh, 1987). Since then, community care evolved to also dominate or influence aging services and research in Britain, other Commonwealth nations, and beyond. While the meaning of community care was often criticized as ambiguous and varying, it emphasized care of those in need (e.g., physically and mentally disabled people, the frail elderly) in the community, or helping people to continue living in their own homes rather than hospitals, nursing homes, and other institutions (Rossiter & Wicks, 1982). “Care in the community,” originally claimed as a better solution to the social needs than institutional care, however, generated numerous new questions, concerns, and debates. In order to tease out a comparative study framework from the seemingly endless confusion and contention, one had to clarify the historical factors (empirical-rational, organizational-technological, economic-financial, ideological-­ political, and social-cultural), mainstream ideology, structural parameters (e.g., contents, recipients, providers, and locations of care), practical issues, and policy responses based on a careful examination of the literature (Chen, 1996). The historical forces that had combined to shift the emphasis in policy to community care, for example, included early sociological research and public reaction against institutional care, vastly increasing practical problems associated with institutions such as costs and staffing difficulties, decreasing need to keep clients away from society because much behavior that was disturbing or bizarre could be controlled by drugs and other methods, demographic changes such as population aging, and growing

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

57

opposition to welfare spending along with the recognition that people had a right where possible to live among ordinary people in society and not to be in a separate institution (Tinker, 1984; Walker, 1982). Johnson (1987) notes that community care was born in such a time that “welfarism” was on a full wing; it is thus quite natural that the original meaning of community care was mainly confined to the formal domiciliary services provided by statutory personnel. During the 1970s, however, the economic performance of the Western world deteriorated sharply, resulting in a dramatic turn-around of the “societal norm” regarding social welfare. The welfare states were believed to have suffered from the problems of government growth leading to overload (Rose, 1980), for which Keynesian economic policies and Beveridge-style welfare policies were held (at least partly) responsible. By the 1980s, there had been much criticism and much talk of the welfare state in crisis, forcing a retrenchment in social policies and a change in emphasis which led to the so-called welfare pluralism. Welfare pluralism (or “mixed economy of care”) is a term used to convey the fact that social and health care might be obtained from four different sectors—the statutory, the voluntary, the commercial, and the informal (Johnson, 1987). However, “welfare pluralism implies a less dominant role for the state, seeing it as not the only possible instrument for the collective provision of welfare services” (Hatch & Mocroft, 1983, p. 2). Johnson (1987) further points out that community care “as a policy objective is by no means new, but recent events have, of course, strengthened the commitment of governments to community care since it appears to offer the opportunity to cut public expenditure and reduce the role of the state. Especially, defining community care as care by the community is more in line with the ideas of welfare pluralism” (p. 67). “Care by the community,” then a new meaning for community care, could be a venerable aim to involve outsiders in the provision of care in various ways (Payne, 1986). The increasing reliance on the informal sector—family, friends, neighbors, and other volunteers, however, left people with many unanswered questions. In practice, scholars had long expressed their concern with a double equation of “community care = family care = care by women” (Finch & Groves, 1980). Despite the “domiciled care” policy outlined by one official report after another under Margaret Thatcher (e.g., the 1988 Griffiths Report and the 1989 White Paper), researchers challenged the assumption that community care would be cheaper than institutional care. As Kinnaird, Brotherston, and Williamson (1981) had already pointed out, it was cheaper because the accommodation and the services of the family were not counted; it’s not necessarily cheaper in terms of social cost. Some critics had already seen community care policy as a failure and demanded “care for the community” as another, necessary dimension of community care, which is a state or government responsibility to support the caregivers (Walker, 1982). As for the future of community care, it should be envisioned with some important forces, visible or invisible, being taken into account, such as the New Right’s claim for a minimal state and others’ for the socialism. By saying this, Johnson (1987) insinuates the importance of a grasp of the general position of social policy to the understanding of the potential development of community care both in theory and in practice.

58

S. Chen and J. L. Powell

The National Health Service and Community Care Act of 1990 outlined community care reforms in the hope to regain momentum. However, after years of operation and evaluation no clear conclusion was reached, leaving “care in chaos” (Hadley & Clough, 1996). For healthcare recipients, a recent literature review by Killaspy (2006) shows that community care was consistently associated with greater patient satisfaction and quality of life across mental health specialties. However, it was not a cheaper alternative to hospital care and it caused an exodus of experienced inpatient staff to community settings with the development of alternative institutions in the non-statutory sector (ibid.). For the family and other informal caregivers under an uneven burden of “care by the community,” questions remain as to how the government would fulfill its role as once a leading welfare state to support them. Its agenda might be too overwhelmed by welfare reform, economic recession, anti- terrorism war, etc. to sustain the advancement of community care with necessary and adequate “care for the community.” On the other hand, the role of the commercial sector in community care has not been a constant focus of inquiry even after years of effort in privatizing public and social services. Particularly, how to engage businesses by turning the “mixed economy of care” into real opportunities for the home-­ building industry, etc. is not yet settled. Most recently, a case study of the British system was provided by updating the current situation of community care in terms of “personalization” (Powell, 2012). The personalization agenda means a major shift in the way social care and individual support providers approach service. The update covers the conceptual and policy underpinnings of personalization and its relation to substantive issues in self-directed care. Trying to locate through research studies and thematic areas a baseline for measuring critical success factors, the update identifies the themes that emanate from IBSEN report of 2008 as benchmarks to measure the effectiveness of the pilots of personalization, social care, and Individual Budgets in the United Kingdom and other Western societies (ibid.).

4.3  Community Service Aging in community has been a complex and complicated subject in the West in terms of the controversies over community care policies as shown by the British case. Aging in Chinese communities could be an even more intricate field because of the vast differences between its urban and rural areas. Rapid social changes over the past three decades have also challenged any attempt to apply or derive a paradigm in the hope to last very long. However, the study of China’s experience should help to enrich our understanding of aging in community from a unique historical and comparative perspective. Prior to the start of sweeping socioeconomic reforms at the turn of the 1980s, China practiced an “occupation-based” system in which state- and collective-owned enterprises “ran society” in terms of performing various social control and welfare functions on behalf of the government (Chen, 1996). In the countryside, it was the

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

59

People’s Commune and its production teams that took care of, for instance, the childless elderly who could no longer earn their own living as they aged. The economic reform after 1978 quickly broke down such an old safety net by dismantling the rural People’s Communes and getting rid of the “iron rice bowl” (lifetime guarantee) for urban workers. The state tried to make up the loss of security with a “serialized reform” to “socialize” welfare provisions. One measure was to build up government-controlled pension funds based on new taxes while relieving enterprises from the uneven burden of direct welfare provision, which was deemed a major obstacle to starting equal market competition (ibid). The process, however, lagged behind economic reform while many non-monetary provisions fell through the cracks. It was in such a situation that some innovative leaders in the reformist government discovered the potential utility of the “community” in the face of mounting social needs, with a desire to learn from the “advanced experiences” of Western nations (Chen, 1988, 1996). “Aging in community” at the time had several “Chinese characteristics.” First, few Chinese people knew even what “community” meant, in Chinese or other languages, not only because most social science disciplines had been nonexistent for nearly 30 years but also because the people were so used to the occupation-based system, belonging only to their almighty Danwei (work unit) for all sorts of needs, that few cared about the “Street” (administrative division of Chinese urban neighborhoods). It was usually after retirement that one might “return” to the neighborhood by playing a role in the Residents’ Committee, etc. (there was no statutory retirement for peasants in the countryside, where local communities were organized as production teams). Second, while Chinese grassroots communities were well organized and effective in terms of social control, there was a lack of social service (particularly voluntary, nonprofit, or nongovernmental) organizations except local government agencies and collectives providing minimal care for some special groups such as the childless and dependent elderly (who were few, thanks to a relatively young population with a norm of large numbers of offspring). Third, there were a heavy reliance on and strong belief in family support (probably the only familist idea favored under the communist ideology), so that when the community service movement started some Chinese scholars fervently argued against overstating the need for developing social services in favor of family support as a virtuous cultural tradition (Chen, 2017a). More researchers, however, were concerned about the negative side effects of economic reform affecting the elderly in the face of a “gray tide” coupled with a dramatic change of the family structure in China. Using today’s terminology, “aging in place” would mean aging in “empty nests” with little home- and community-based service given the nation’s “one child” policy in the urban areas and rural labor migration to the cities. The economic reform required welfare services (including housing provision) to be removed from the workplace to the community, yet the “community” was not prepared to take over that omnipotent role of the Danwei while nursing homes were almost unheard of (Chen, 1996). This could mean “aging in no place” for the majority of the Chinese aging population. Despite all the research findings, scholarly appeals, practical demands, and real problems, the reformist but still (self-proclaimed) socialist state appeared to be

60

S. Chen and J. L. Powell

doing little to support the family and the “community” at the time of a hyped movement of community service (which changed to “community construction” later). Watchdogs outside China could not help but kept complaining. The paradoxical situation would drive the analysis in aging study all the way up to the level of a “general public policy” (GPP) in order to understand why that was the case and when a policy change could be expected from the “economic state in transition” (Chen, 1996, 2010). Just as the welfare state in crisis had to take a turn with welfare reform, the economic state in real crisis (as a consequence of continued politicization culminating in the “Cultural Revolution”) had no choice but to undertake economic reform. Compared with American “workfare,” China took an opposite direction by laying off redundant employees from state- and collective-owned enterprises. Privatization further diminished the status of many (as once the “masters” of their workplaces and jobs), and peasants in the countryside were left on their own with tiny pieces of land to produce or lose. Ordinary people, particularly disadvantaged groups, paid the price of losing their Danwei-based social protection, once deemed a major indication of the “superiority of socialism.” Similar to the shift from “welfarism” to welfare pluralism in the West, social policy of the economic state changed its aim from a superior “iron rice bowl” to a socialist welfare pluralism (Chen, 1996). The state promised to “get rich together” after economic catch-up (Chen, 2010), which would include social security for the unemployed and the elderly. The desperate need to survive its legitimacy challenge by making up past loss of economic opportunities under extreme politicization, however, required its changed GPP to focus almost exclusively on the economy. This was made crystal clear by the post-Mao leadership’s declaration of a “strategic transfer” of its work emphasis onto economic construction. It was this strategic transfer that made the economic reform possible after 1978. Those confusing “-isms” (i.e., socialism vs. capitalism), which had always taken the center stage of Chinese policy and frequently disrupted economic production, were put aside, with Deng Xiaoping effectively silencing ideological argument with his famous “white cat or black cat” principle to allow the newly de-politicized economic state to wage economic and all-encompassing (except political) reform (Chen & Cai, 2018). As predicted (although not without luck), in creating an economic miracle a new social security system with minimum income guarantee was built up. And housing ownership was given to workers and staff (often at a token price) (Li & Chen, 2010), which provided the aging with a place in the urban community. Voluntary or nongovernmental organizations have also been on the rise. The elderly, however, had little savings while younger generations, or the elderly of the future, did not benefit from that unique real estate property rights transfer (privatization). Other services such as health and long-term care have remained problematic for all (Chen & Chen, 2007). With the majority of the Chinese elderly now living alone or only with spouse (Li & Chen, 2010), both housing policy and home-building practice have largely neglected the needs of the aging (as both social challenges and economic/business opportunities). Even less attention has been paid to the needs of older adults in the rural areas. There has been a rapid change of the situation, however, after the issue was pointed out with an article frantically reprinted by almost all related government and professional websites after it was published (Chen, 2011).

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

61

Outside the urban areas, Luo and Zhan (2012) examined how functional solidarity impacted normative solidarity (filial piety) among families with migrated children in rural China. Analyzing data from a survey of 1443 elders in three inland migrantexporting provinces of China, their findings suggest both a continuation of traditional norms and an adjustment of rural elders’ expectation for filial piety. Due to economic constraints faced by rural families, financial support was perceived as an important aspect of filial piety by rural elders. It is interesting that elderly parents who took care of grandchildren had a more positive evaluation of filial piety than those who did not. Taking into consideration the economic and cultural context of rural China, the authors conclude that functional support (in the form of intergenerational exchange) plays an important role in shaping and changing the face of filial piety as rural–urban migration progresses. Policy-wise, the Chinese government structurally is no longer an economic state after numerous economic and administrative reforms including privatization (Chen & Cai, 2018), which led to dramatic de-economicization of itself (Chen, 2010). Capitalism has taken roots in the country with remarkable economic achievements as well as serious social issues such as stunning inequality, poverty, and unemployment. Yet the economic state ideology would still influence its GPP during the transitional period. This had better be considered a new “post-economic state” GPP, which means that the Chinese state will neither be an economic state nor a welfare state after the 19th Congress of CCP declared that the main goal of the country would be to seek both “balance” and “sufficiency.” It remains confusing whether the market economy is socialist as claimed or indeed capitalist (for even state ownership is not necessarily ownership by all). The government is now expected to learn more from the modern welfare state than early Laissez-faire capitalism. Given that the Western welfare state is also seriously handicapped, it remains to be seen whether or not the Chinese state will be able to move beyond (rather than a mere “convergence” with) the former to fulfill its promise of ultimate socialist welfare based on the market economy. In such a situation, the society has not found a clear answer as to how to support aging in community. Progresses have been made in community health, education, and recreation, though personal social and psychiatric services for the frail elderly and the disabled are still wanting in urban and rural communities, along with the issue of blatant employment discrimination against older adults under a high pressure of youth unemployment. As a developing country, the needs for more resources to support families and voluntary organizations are evident. A question is how to unleash the social potential of its rapidly advancing industries in the commercial sector.

4.4  Social Support Unlike the Chinese and even the British, Americans tend to sanction more limited government and sometimes (if not always) appear to favor empirical research over policy speculations (as such they seem no less effective in leading various trends

62

S. Chen and J. L. Powell

with innovations). One of the “culture shocks” after the first author relocated to the United States was to discover some unique features of American social policy studies. Community care and service were heard (not without learning from the experiences of other nations, especially the British Commonwealth), but it was not so prominent or symbolic to American scholars and policy-makers as to their British or Chinese counterparts. The terminology for public discourse could be more varied to include such other key terms as home-based, community-based, and long-term care (LTC) with more pragmatic or programmatic interests than arguments over, for instance, the differences between care in, by, and for the community. Neither community care nor community service made an overarching theme or became the center of a lasting policy dialog (Cox, 2004). Instead, a heated subject was called “social support,” or “social support network,” which did not stem from an official push but was popularized via health-related research. Since biomedical models of diseases appeared to have reached their limits, social and behavioral scientists weighed in with the evidence that morale and well-being are sustained through primary group ties, whose absence may result in psychological disorders and social problems (Lin, Dean, & Ensel, 1986). On the other hand, psychodynamic thinking such as Freudian theory suggests the importance of early attachment and the needs served by later social relationships that in some views harken back to childhood issues (Vaux, 1988). Epidemiologists John Cassel (1974) and Sidney Cobb (1976) laid much of the groundwork for the discussion of the psychosocial processes implicated in disease etiology. In particular, Cassel (1976) argued that social support plays a key role in stress-related disorders, and both animal and human studies had provided evidence supporting this point of view. Such a “stress-buffering” hypothesis underlay much of the interest in social support (Chen, 1997). With more and more researchers participating in this type of studies, the role of social support in maintaining good mental health was widely recognized in the 1980s. While aging is not a disease, aging and health tend to be studied together by gerontologists or geriatrists (e.g., Levkoff, Chee, & Noguchi, 2000). In terms of a “buffering effect” of social support (Chen, 1997), Dr. James E. Lubben was among the pioneers in applying social support theory to aging studies. The Lubben Social Network Scale (LSNS) was widely used (http://www.lubbensocialnetwork.org/, retrieved November 23, 2010), even after some other researchers became more interested in a related term of “social capital” integrating economic thinking (Lin, 1999; Putnam, 1995). The LSNS was a brief instrument designed to gauge social isolation in older adults by measuring perceived social support from family, friends, and neighbors in terms of the size, closeness, and frequency of contacts of a respondent’s social network. Originally developed in 1988 and revised in 2002 (LSNS-R) along with an abbreviated version (LSNS-6) and an expanded version (LSNS-18), the purpose of the tool was to meet clinicians’ needs and for basic social and health science research. Both the LSNS and the LSNS-R distinguish between kin and non-­ kin though they do not differentiate between friends and neighbors. The tool has been used in settings ranging from the community to adult day care centers, to assisted living facilities, to doctors’ offices, and to hospitals (ibid.).

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

63

Note that even the LSNS with a focus on the informal sector of social care specified no space factor that might dictate a debate or deliberation over living arrangements or care settings as seen in some other countries. This is probably because community care (or service) had never been made a central theme for aging study in the United States, sometimes referred to as America’s “non-system” of community support for disabled elderly persons (Scharlach, 2004) even with the efforts of such networks as the National Association of Area Agencies on Aging (n4a, http://www. n4a.org/, retrieved November 23, 2010). In a later article, Scharlach (2012) describes the types of community aging-friendly initiatives that currently exist in the United States, and the roles that various sectors (e.g., public, non-profit, private) have played in their development. An Internet-based survey identified 292 aging-friendly community initiatives that fell into four types: community planning, system coordination and program development, co-location of services, and consumer associations. Most local community interventions had been developed, and often hampered, without federal funding or guidance. Private sector solutions appear to be on the rise though such initiatives were not widely accessible. The findings raise questions regarding the sustainability of those efforts, their availability to less-resourced individuals and communities, and the long-term ability of communities to make the infrastructure changes without an increasing government role. In terms of service locations, it is presumable that after people finally realized that they had to do more to highlight the importance of the home (if not the family) and the community, they would have to reinvent the American version of social care, service, or support with a community focus, or at least to link it with a “place.” A real breakthrough, however, was not brought about by a pure scholarly or public policy interest but by the “invisible hand” of the market.

4.5  Aging in Place (AIP) It is not easy to summarize how “aging in place” (AIP, also “age in place”) has gained its own place in contemporary policy, practice, and research. Some would trace it all the way back to Franklin Roosevelt in 1938, just like those who held Emile Durkheim (particularly his study of suicide in 1897) originally responsible for “social support” as a hot topic amid the surge of social or psychosocial epidemiology in the 1980s (Vaux, 1988). Some argue that Roosevelt might not have invented AIP, but he was among the first to apply its principles in adapting a private place of his to suit aging and disability needs (http://blogs.consumerreports.org/home/ aging_in_placeuniversal_design/, retrieved November 20, 2010). Then, 70  years later, why is AIP just reaching the mainstream? The needs of the aging but predicted longer and healthier-living baby boomers as a huge population of consumers for “aging-in-place environments” are cited as a main reason, which are preferred over such alternatives as assisted-living centers and nursing homes (ibid.). Such an anticipated shift of consumer interests and demands caught the attention of the mammoth health care, home-building, and financial industries and various

64

S. Chen and J. L. Powell

other manufacturers, suppliers, and service providers along with academic, public policy, and market researchers. By 1989, there had been much talk about AIP (e.g., Howard, 1989) with conferences and publications (e.g., Tilson, 1990) and even congressional hearings (e.g., United States Congress, 1989) and the White House Conference on Aging bearing that theme. After continued development over the next decade in this direction, a national AIP movement came along (Allen, 1999), if not yet widespread. The first annual National Aging in Place Week in November 2003 was sponsored by the National Association of Home Builders, the National Advisory Council on Aging, and the National Reverse Mortgage Lenders Association, with educational and informational events taking place in seven US cities. In 2004, Partners for Livable Communities and the National Area Agencies on Aging began working with nine laboratory communities in advancing policies, programs, and services to promote AIP.  With baby boomers entering old age, demand for services is at an all time high while most of them wanted to remain in their current home (Mathew Greenwald and Associates, Inc., 2003). And AIP as an idea is finally prevailing or popularized, with the establishment of a new profession (or professional qualification) called Certified Aging in Place Specialists (CAPS) sponsored by state and national associations of home builders (NAOHB). Just as the meaning of community care became complicated in its evolution, AIP has meant differently to different people along the way. Historically, life-care communities (a.k.a. “continuing care [retirement] communities,” or CCRC) were designed for AIP as one of the three main categories of group housing for the elderly (Allen, 1989). AIP initiatives then referred to multiple levels of services within one campus/senior community. “Aging in place” today is still a term used in marketing by those in the rapidly evolving senior housing industry, embraced by such organizations as the American Association of Homes for the Aging which represents nursing homes, retirement communities, assisted living residences, and senior housing. Yet, for home-builders seeking to expand business in all desirable ways, it also meant adapting or modifying existing homes (called “retrofitting”) to support people being able to stay there as they age until universal design grows more widespread. Thus, the AIP movement is sometimes called “Aging in Place through Home Modifications” (Kofsky, n.d.). This is important for a belief in “naturally occurring retirement communities” (NORC), which defines AIP as growing older without having to move as required for such built environment as group housing (where one must move in first; in many cases, one must also move from one wing of the campus to another to receive increased services) (http://www.seniorresource.com/ageinpl. htm, retrieved November 27, 2010). So AIP means staying in one’s present residence or living where one has lived for many years in a non-healthcare environment and using products and support services to enable him or her to not have to move as circumstances change (ibid.). By reducing forced move, older adults may avoid relocation stress syndrome (a.k.a. transfer trauma). Early planners for housing development actually only referred AIP to the phenomenon or tendency of residents growing older as a bloc in the community (called “silting up” as it would increase the need for expensive healthcare services and make younger people reluctant to move in). Demographers also used the term to

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

65

simply describe locales or communities where, over time, concentrations of persons aged 65 years and older developed (Morrill, 1995). It was estimated that some 70% of seniors had already spent the rest of their life in the place where they celebrated their 65th birthday (http://www.seniorresource.com/ageinpl.htm, retrieved November 28, 2010). To the advocates for independent living, however, it is the ability to live in one’s own home of choice and community—wherever that might be—for as long as confidently/safely and comfortably possible (even if it will become assisted living to certain degree) that guides the mission for AIP (http:// www.aipathome.com/about-us/, retrieved November 27, 2010). Therefore, the emphasis of the AIP movement is on livability (http://www.aginginplaceinitiative. org/, retrieved November 28, 2010), or comfort and safety, of home with seniors having a choice in their care and living arrangements (be it in group housing, natural bloc, or alone) that will be extended to support independent living in later life. This entails the programs that go beyond what is required in the Americans with Disabilities Act to create both accessible and attractive settings for the elderly. On the other hand, laws and regulations can be amended to permit and facilitate AIP developments since federal and state regulations of long-term care may make AIP difficult if not impossible (some states passed legislation around the turn of the twenty-first century to designate some AIP demonstration sites so they would be regulated differently from traditional residential care/assisted living and nursing homes) (e.g., Sinclair School of Nursing, 2010). Compared with the other efforts reviewed earlier in this chapter, an outstanding feature of AIP is the recognition or “buy-in” from various industries (i.e., the commercial sector) in terms of their role in promoting aging at home. As such, they help to keep the elderly in the community by creating a safe and comfortable environment for independent living with home modification, universal design, and retirement communities using new technology to ensure extended livability and meet their special and changing needs. By making the environment more supportive of their independence and reducing the risk of falls and the consequences for those wishing to be part of the AIP generation, the stress of their family caregivers is reduced so they may stay and concentrate more on their paid jobs. For the elderly, independence does fade into need for assistance as they continue to age, but living in the same apartment or house allows them to stay in familiar surroundings near friends and neighbors (for as long as safely and comfortably possible which is the goal of AIP). AIP gives older adults leverage in the marketplace while businesses, from medical to construction to finance, are increasingly eager to provide services with government and academic support/partnership. High amenity and high social service housing was the original concept behind the idea of AIP, but it has also produced demands for telecare/telehealth and other communication and assistive technologies for health/ wellness, safety/security, personal social services, entertainment/recreation, learning/education, and contribution. AIP is detail oriented since changes may be made in every room of a home, from simple improvements to extensive remodeling. Commercial providers contributing to AIP may include architects, remodeling companies, interior designers, landscaping contractors, home healthcare

66

S. Chen and J. L. Powell

professionals, geriatric care managers, food and product delivery services, home maintenance crews, transportation providers, financial planners, insurance companies, distance learning programs, and much more (National Aging in Place Council, http://www.ageinplace.org/, retrieved November 20, 2010). AIP has also meant more choices of the elderly in their living arrangements, such as cohousing, elders’ guild, and village networks (http://www.cohousing.org/taxonomy/term/225). Given the decline or stagnation of community care in the West (as well as a once observed shift away from community service in China, see Wong & Poon, 2005), AIP is gaining influence in scholarly thinking and policy dialog worldwide (e.g., Chui, 2008), including the United Kingdom (Freyne, 2010). AIP as a movement, however, has not fully addressed the role of the statutory sector although it is well-­ known that voluntary organizations have long relied on public funding or government grants. For those who were previously exposed to the research of community care, community service, social support, etc., the provision of social services vs. informal care may continue to be their focal interests (Chen, 2017b). The caregiving role or burden of the family and necessary support from the government have remained to be a concern, especially in view of the uncertain future of Social Security funding. AIP services may represent great ideas and deeds, though who are able to afford them can be a big question, especially in view of the erosion of retirement savings of ordinary Americans during recent recessions. Healthcare costs and lack of personal/domiciliary social services are also prohibitive factors despite the needs of the elderly including those living in “empty nests.” The stereotype of wealthy elderly homeowners may not be applicable to all, especially in view of the recent burst bubble of housing market that may take a long time to recover. It threatens “aging in no place” for the homeless despite a noble intent of AIP to enable older people to continue to live in their home safely, independently, and comfortably, regardless of age, income, or ability level. These have limited and will continue to limit the realization of AIP goals, with many older adults unaware of it and some community leaders unsure where to begin (www.livable.org/livabilityresources/16-aging, retrieved November 29, 2010).

4.6  Conclusion Healthy, successful, productive, and active aging in community as an international undertaking requires historical and comparative perspectives to understand the roles of family, community, and social policy in the era of globalization. The Springer Book Series on International Aging (http://www.springer.com/series/8818) has been launched to address the issues of aging in the twenty-first century on a global scale. This volume in the Series focuses on shedding light on the Chinese case in a comparative context, including the meaning of the community beyond a mere place in supporting aging populations in an East-West perspective. Different nations have different stories of aging as well as how they have dealt with it in their own ways as shown by all the country cases mentioned above. Their

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

67

various innovations have influenced and been influenced by one another, however. The First World Assembly on Aging in 1982, for example, greatly affected China’s aging policy which led to a formal expansion of its official aging undertaking, including efforts underpinning the community service movement. The newer policy framework proposed by the World Health Organization (WHO) at the Second World Assembly on Aging in 2002 helped to advance worldwide agendas for research and practice, from healthy aging, successful aging, and productive aging to active aging. All these provided new meaning to aging in community, with older adults as active participants and productive forces, in addition to the recognition of their increasing dependence and needs for caregivers as they continue to age.

References Allen, J. L. (1989, October 29). Group housing for elderly falls into 3 main categories. Chicago Tribune. Allen, J. E. (1999, May 24). Home safe home: A national “aging in place” movement helps seniors stay where they love to live. Los Angeles Times (p. 1). Baugh, W. E. (1987). Introduction to the social services (5th ed.). London: Macmillan Education Ltd. Cassel, J.  (1974). Psychosocial processes and “stress”: Theoretical formulations. International Journal of Health Services, 4, 471–482. Cassel, J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology, 104, 107–123. Chen, S. (1988). Community service (a public lecture series). China Civil Affairs Administration, Nos. 1–4, 6 (in Chinese). Chen, S. (1996). Social policy of the economic state and community care in Chinese culture: Aging, family, urban change, and the socialist welfare pluralism. Brookfield: Ashgate. Chen, S. (1997). Measurement and analysis in psychosocial research: The failing and saving of theory. Brookfield, VT: Ashgate. Chen, S. (2010, June 10). A new turning point of Chinese general public policy: From “economic construction as the center” to “balanced socioeconomic development based on economic growth”. Chinese Social Sciences Today (in Chinese). Chen, S. (2011, January 11). Aging and housing: China’s two major challenges. Chinese Social Sciences Today (in Chinese). Chen, S. (2012). Historical and global perspectives on social policy and “aging in community”. Ageing International, 37(1), 1–15. Chen, S. (2017a). Population aging and social policy: Chinese Jia in elder care research. Population and Society, 33(1), 63–72 (in Chinese). Chen, S. (2017b). Community study, community care for the elderly, and social policy. Population and Society, 33(2), 3–12. https://doi.org/10.14132/j.2095-7963.2017.02.001 (in Chinese). Chen, S., & Cai, X. (2018). General public policy, socialism, and social problems: Social equity, public economics, and social science research in the post-economic state era. Society & Public Welfare, 3, 64–71. (Tsinghua Social Work Review, No.1) (in Chinese). Chen, S., & Chen, E. Y. (2007). Aging and health in the new century: Challenges to research and practice. In I. Cook & J. Powell (Eds.), New perspectives on China and aging. New York: Nova Science Publications. Chui, E. (2008). Introduction to special issue on “ageing in place”. Ageing International, 32(3), 165–166. https://doi.org/10.1007/s12126-008-9016-1 Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic Medicine, 38(5), 300–314.

68

S. Chen and J. L. Powell

Cox, C. B. (2004). Community care for an aging society: Issues, policies, and services. New York: Springer. Finch, J., & Groves, D. (1980). Community care and the family: A case for equal opportunities? Journal of Social Policy, 9, 487–511. Freyne, S. (2010). What are the challenges to healthy ageing in place? Network for Student Activism. Reprint by UCL Centre for Applied Global Citizenship at http://www.ucl.ac.uk/ network-for-student-activism/w/What_are_the_challenges_to_healthy_ageing_in_place%3F Hadley, R., & Clough, R. (1996). Care in chaos: Frustration and challenge in community care. London: Continuum. Hatch, S., & Mocroft, I. (1983). Components of welfare. London: Bedford Square Press. Howard, W. (1989, January 1). New program lets elderly choose nursing home or independent life. Providence Journal, C-02. Johnson, N. (1987). The welfare state in transition: The theory and practice of welfare pluralism. Sussex: Wheatsheaf Books Ltd. Killaspy, H. (2006). From the asylum to community care: Learning from experience. British Medical Bulletin, 79/80, 245–258. https://doi.org/10.1093/bmb/ldl017 Kinnaird, J., Brotherston, J., & Williamson, J. (Eds.). (1981). The provision of care for the elderly. Edinburgh: Churchill Livingstone. Kofsky, B. (n.d.). “Aging in place” through “home modifications”. Retrieved October 29, 2010, from http://www.hatfl.com/Aging_In_Place_home_modifications.pdf Levkoff, S. E., Chee, Y. K., & Noguchi, S. (Eds.). (2000). Aging in good health: Multidisciplinary perspectives. New York: Springer. Li, B., & Chen, S. (2010). Aging, living arrangements, and housing in China. Ageing International, 36(1), 463–474. https://doi.org/10.1007/s12126-010-9094-8 Lin, N. (1999). Building a network theory of social capital. Connections, 22(1), 28–51. Retrieved from http://www.analytictech.com/mb874/Papers/lin-socialcapital.htm Lin, N., Dean, A., & Ensel, W. (1986). Social support, life events, and depression. Orlando: Academic. Luo, B., & Zhan, H. (2012). Filial piety and functional support: Understanding intergenerational solidarity among families with migrated children in rural China. Ageing International, 37(1), 69–92. Mathew Greenwald & Associates, Inc. (2003). These four walls… Americans 45+ talk about home and community (research report). Washington, DC: AARP. Morrill, R. L. (1995). Aging in place, age specific migration and natural decrease. The Annals of Regional Science, 29(1), 41–66. https://doi.org/10.1007/BF01580362 Payne, M. (1986). Social care in the community. London: Macmillan Education Ltd. Powell, J.  L. (2012). Personalization and community care: A case study of the British system. Ageing International, 37(1), 16–24. Putnam, R. D. (1995). Bowling alone: America’s declining social capital. Journal of Democracy, 6, 65–78. Rose, R. (Ed.). (1980). Challenge to governance: Studies in overloaded politics. London: Sage. Rossiter, C., & Wicks, M. (1982). Crisis or challenge? Family care, elderly people and social policy. London: Study Commission on the Family. Royal Commission on the Law Relating to Mental Illness and Deficiency. (1957). Report (Command 169). London: HMSO. Scharlach, A. (2004). Book review comments. Retrieved October 2, 2011, from http://www.amazon. com/Community-Care-Aging-Society-Lifestyles/dp/0826128041/ref=cm_cr_dp_orig_subj Scharlach, A. (2012). Creating aging-friendly communities in the United States. Ageing International, 37(1), 25–38. Sinclair School of Nursing. (2010). The aging in place project: Assuring quality at-home services for seniors. American Academy of Nursing. Retrieved November 1, 2011, from http://www. aannet.org/files/public/AgingInPlace_template.pdf Tilson, D. (Ed.). (1990). Aging in place: Supporting the frail elderly in residential environments (Conference Proceedings). Glenview: Scott, Foresman.

4  “Aging in Community”: Historical and Comparative Study of Aging Welfare…

69

Tinker, A. (1984). The elderly in modern society. New York: Longman Group Ltd. United States Congress. (1989). Aging in place: Problems and solutions for older residents of New Jersey (hearing before the Subcommittee on Housing and Consumer Interests of the Select Committee on Aging, House of Representatives) on February 27 at Toms River, NJ. Document printed by U.S. G.P.O. Vaux, A. (1988). Social support: Theory, research, and intervention. New York: Praeger. Walker, A. (Ed.). (1982). Community care: The family, the state and social policy. Oxford: Blackwell Martin Robertson. Wong, L., & Poon, B. (2005). From serving neighbors to recontrolling urban society: The transformation of China’s community policy. China Information, 19(3), 413–442.

Internet Sources Retrieved November 20, 2010, from http://blogs.consumerreports.org/home/aging_in_placeuniversal_design/; Retrieved November 20, 2010, from http://www.agingincommunity.com/ Retrieved November 20, 2010, from http://www.ageinplace.org/ (National Aging in Place Council); Retrieved November 28, 2010, from http://www.aginginplaceinitiative.org/; Retrieved November 27, 2010, from http://www.aipathome.com/about-us/; Retrieved November 27, 2010, from http://www.cohousing.org/taxonomy/term/225; Retrieved November 29, 2010, from http://www.livable.org/livability-resources/16-aging; Retrieved November 23, 2010, from http://www.lubbensocialnetwork.org/ Retrieved November 23, 2010, from http://www.n4a.org/ Retrieved November 27, 2010, from http://www.seniorresource.com/ageinpl.htm; Retrieved November 27, 2010, from http://www.springer.com/series/8818

Part III

Nordic Countries

Chapter 5

Sweden: Aging Welfare and Social Policy in the Twenty-First Century Sven E. O. Hort

“The object of government in peace and war is not the glory of rulers or races, but the happiness of the common man.” William Beveridge, 1942

5.1  I ntroduction: Aging Welfare and Social Policy in the Twenty-First Century Aging is a key feature of modern societies, within sight the possibility of a happy end, a future for posterity? According to an international calculation, in a decade or two there will be some two billion human beings above age 60 and well over half of them will lack adequate resources and income maintenance systems (UN, 2017). All over the globe, across continents and, thus, including the developing world with its fairly young current populations, it will not be all that long before there is a radical shift towards an aging society. Perhaps most alarmingly, already in this first decade of the new Millennium, the oldest old (80+) was the age group growing most rapidly. In three decades, of the globe’s predicted ten billion people, more than 20% will be 60+, most of them in countries that in 2015 do not have sufficient old age protection and where such issues as health, disability, shelter, and income risks, to name a few, do not have high visibility. Also in the Sweden, in comparative perspective a rather healthy and prosperous society, the elderly are a significant social category although more diverse than the geriatricians, gerontocracy, gerontologists and other key players in the aging business are sometimes prepared to admit. True, a majority of those in Western Europe, Japan and North America who cross the threshold of 60 or 65 enter a third age that releases them from the confines of adult work schedules and is financed to a con­ siderable degree by public and semi-public pension schemes, i.e. a leisured class.

S. E. O. Hort (*) Linnaeus University, Kalmar and Växjö, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_5

73

74

S. E. O. Hort

But throughout the developed world, including Scandinavia to a lesser extent, not to speak of the developing countries, there are still large social differences—inequalities and inequities—between the healthy and the sick, between women and men, between recently retired and oldest old working class people, and between well-to­do and less fortunate pensioners. Social policy became a key tenet of twentieth century European modernity beginning in Germany with Bismarckian social insurance schemes, continuing with the midcentury “all-encompassing” Beveridgean welfare state in Great Britain, and p­ erhaps ending with “Social Europe” and the return of the Nordic welfare model (Alestalo, Hort, & Kuhnle, 2017; Hort, 2018; Kuhnle & Sanders, 2010; Renswick, 2017). Is there something for the global community to learn from this century-long experience of constructing human security not least for old and work-­incapacitated people? What kind of welfare institution-building and policies will the rest of the twenty-first century have in its wings? Taking the imagined community of Sweden as an advanced welfare state with a long history of policy developments and institution-building in this article I will discuss some key aspects of the relationship between aging and the welfare state: (1) territory, demography and economy, (2) the institutional welfare state as social administration and policy arena, (3) retirement pensions, personal health and social services and housing as a key common-­pool-resources-institutions in a capitalist market economy, (4) social mobilization in civil society and the role of voluntary associations for elderly people, and finally (5) as preliminary conclusions highlighting these interdependencies (1–4) in the mature welfare state at present explicitly posed by longevity, mass consumption and potential suffering. It is based on research conducted over almost 40 years including follow-ups of various official or semi-independently sponsored evaluations, a paper presented at a conference in Beijing in June 2015, slightly revised in the early winter months of 2018 (cf. Hort, 2014, 2015; also Hort, Kings, & Kravchenko, 2016 for further references and sources).

5.2  Territory, Demography and Economy China is the world’s fourth largest territory while Sweden holds the same position for Europe otherwise these two are fundamentally different entities as society and state (cf. Chang, 2016; Rothstein, 2015). Moreover, in the Far North there are four culturally and economically closely integrated nations-states: Denmark, Finland, Norway and Sweden, parts of its south being fairly densely populated areas, otherwise most of this region extremely sparsely inhabited, fairly isolated close to the Arctic circle also by cross-bordering Sami people with national citizenship in Finland, Norway or Sweden depending on domicile. Historically kingdoms have come and gone but mostly this territory has been divided between west—Denmark-­ Norway—and east—Sweden-Finland—Scandinavia. Linguistically Denmark, Norway and Sweden are close to each other, and there is a significant Swedish-­ speaking minority in Finland, Finnish an entirely different language. With the exception of Norway, since the mid-1990s these countries are all members of the

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

75

European Union, Denmark already from 1973. Sweden is the largest and most populated of these countries. Also in terms of aging, these countries are exceptionally similar, and often on top of global indexes. Administratively Sweden is divided into some twenty territorial counties and almost 300 municipalities—as legal units constitutionally county councils and municipalities are on par. Most people live in the urbanized parts of the south but elderly people are more evenly spread around the country. Compared to China’s millions of 65+, Sweden’s two million pensioners are miniscule. Nevertheless demography matters although the elderly as a conceptual social category have not yet become a historical subject in the voluntaristic sense. There are asymmetrical relations between young and old that go beyond purely biological asymmetries as part of the social stratification of modern stratified societies but within-group differences are larger. Historically young people have generally been held in less esteem and have had weaker power positions and less economic resources than their elders. Nonetheless, age groups are not always perceived as distinct social layers; it is rather the case that within each social group as in every family there is an intrinsic inequality between young and old. Death and dying has not been eliminated and old people do not grow older indefinitely. Although unequal age relationships change fairly slowly in society in general, most people experience them as they pass through life, for instance people may move from one social stratum to another, down or up in existing social hierarchies. This social mobility may be manifest in the life of an individual but it may also occur from one generation to another. At the collective level, a social generation may thus be seen as a birth cohort sharing certain chronological and spatial characteristics and experiences. These historical conditions make up the cultural background of the lives of all those belonging to a particular cohort or social generation (cf. Lundberg & Månsson, 2017). In Sweden, those at the end of life during the second decades of the new Millennium—the oldest old—were born prior to or during the Great Depression and adolescents during the next Great War in which despite its proximity Sweden again remained outside. The generation born during the 1920s and 1930s is the smallest of all twentieth century cohorts. Furthermore, the 1940s baby boom occurred somewhat earlier in Sweden, immediately after Stalingrad and the domestic regulation of housing rent. The children born in the 1940s and 1950s benefitted from rapidly growing material prosperity and the emergence mass consumption culture among the young pointed towards changing social power relations between them and older people. Later, this generation has been accused of crowding later cohorts out—a generational battle fought in particular by their offspring from the 1970s and 1980s—but is now leaving the labour market and maybe other important power positions. In 2015, of Sweden’s total population of nine million, more than two million or 23% were over 60 and roughly 1.5 million were over 65. Morality and fertility rates roughly match each other; net population increase is behind population increase. Another partly overlapping but considerably younger two million were, thus, born abroad or had at least one parent born abroad—a major demographic transformation of a historically rather homogeneous society with the Sami in the Far North as the

76

S. E. O. Hort

historical major “other”. Turning to the elderly, defining the oldest old 80+ puts half a million Swedes into that category while another 400,000 would be added if this threshold is lowered to 75+, thus, a total of 900,000 or almost a tenth of the total population. Raising the threshold gives well over 200,000 in the 85+ category, of whom some 75,000 are 90+. Of the latter, 55,000 are women reflecting the gender difference in average life expectancy. At present women have an average lifespan of 84 years, men 81. Furthermore, women who reach the age of 65 live on average for another 21 years, while the figure for men is 18 years. Over the years, these statistics show a linear increase in these respects although men have had somewhat more favourable development than women for more than a decade. Besides being gendered these life expectancy figures have both class and regional dimensions (Therborn, 2014). It is well-known that people of working class origin and experience die younger than those who have spent their lives in for instance office work or money laundering. Only some 60 years ago, remaining average life expectancy at age 65 did not differ between men and women in Sweden which had to do with women’s working conditions in those days in the home as well as elsewhere. Working class women benefitted tremendously from having fewer children as well as from technological improvements in the home and at work though some of the most radical feminists fought for equal treatment in the mines and on night shifts. Even in 2018, men who have spent their lives in manual jobs die much earlier than others, particularly if they are or have divorced. The class dimension is also a matter of control of territorial material and monetary resources as well as the possibility of social mobilization. However, the demographic potential may transcend class boundaries. This was hotly debated in Sweden during the decades of emigration to North America when roughly one million out of five left for better prospects on the other side of the Atlantic. Although the human numbers have always been small, the emphasis on size is relevant in the Swedish case, where a rather vast and resource-rich territory has been exploited by export-­ oriented private enterprise and the material surplus gradually became more evenly distributed since the breakthrough of modern social mobilization and organization. In the twenty-first century when inflow instead of outflow is the dominant mode of migration, a debate about social exclusion in ethnically segregated metropolitan areas is accompanied by on the one hand an awareness of the need to utilize the capacity of the newcomers to the country, and on the other hand a divisive incorporation of them in the affluence of Swedish society and state, or not. The latter includes a contested issue of elderly immigrants—many of them arriving after their labour immigrant children—as well as all those working in the elderly care sector as nurses, home helpers, janitors, medical doctors, etc. Following conventional economics, Sweden belongs to a group of countries whose Gross Domestic Product is among the top 25 in the world (Persson & Sharp, 2015). Private companies dominate the economy though a large share of the GDP goes through the state coffin— taxes and transfers—whether central or local-regional. Taken together Sweden is a sensitive export-oriented economy but came out of the most recent 2008–2013 American-European financial crises rather favourably. Together with neighbouring Denmark, Finland and Norway this region as a whole would belong to the top 15

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

77

economies in the world. Nordic intra-trade has increased over the years and an open Nordic market has improved employment prospects in general. Still these economies are most vulnerable to global macro-economic volatility as well as similar domestic events. A turn to a different and more difficult situation is within sight, hence some elderly men and women are more fragile and frail than others.

5.3  T  he Institutional Welfare State as Social Administration and Policy Arena In addition to these territorial, demographic and economic starting points, it is necessary to point out a few basic characteristics of tax-financed state obligations and social rights, or common-pool-resources-institutions in the imagined community of Sweden. First, there is its universality which goes back to the adoption and adaptation of ideas of a Bismarckian worker insurance in the 1880s, actually a forerunner to the well-known Beveridgean Welfare State. In this respect the Swedish Welfare State can be regarded as the secular successor of the Lutheran State Church, from the sixteenth century the civil arm of the military state with compulsory church membership up to 1952. Already during the eighteenth century it had reached out with its alphabetization programme and spread literacy among the great majority of the population, thereby preparing the ground for the revivalist Christian popular social mass movements or “free churches”. Thus, boundaries between state and society—private and public—have been both muddled and enabling. The “stateness” of society or imagined community is comprehensive in its penetration (“the people’s home” and the “Swedish model” of political compromise and peaceful labour market agreements) but so is the “societyness” of the state (“our state” or the “strong society”—a “movement state”). For long it was the relationship between the highly centralized corporatist labour market organizations that stood out: the employers’ association recognized the national organization of blue-collar trade unions as their sole counterpart. Social democracy’s long political reign, either alone or in coalition with support from the right as well as the left during most of the twentieth century has given rise to the global notion of a decommodified social democratic welfare regime and even a “socialdemocratization” of the world (Törnqvist, 2017; cf. also Kuhnle, 2017). Hence, it is a “big” welfare state—in terms of tax-income and public social spending as well as numbers employed and unionized human beings—with a comprehensive set of provisions conditioned primarily on citizenship, age and residence so far with broad-based popular support and an absence of pervasive fraud and similar corrupt practices (Svallfors, 2013). It is a state—embedding market dynamics and, thus, itself embedded in an imagined community where monetary relations thoroughly imbue everyday life—which takes responsibility for a range of measures intended to ensure the well-being of its members for instance by providing education for children and adolescents, access to healthcare, shelter and housing over the lifespan, financial support for periods out of work and personal social services in the event of disability or other hardship; all of which inscribed in §2 The Instrument of

78

S. E. O. Hort

Government in the 1974 Constitution of Sweden. Already prior to that date, the normative foundation of the Scandinavian or Nordic welfare state had been put forward as a model to emulate or reject. Hence, it is a welfare capitalism regime in which the state guarantees a certain level of welfare as well as functioning markets, voluntary associations in civil society and families and households—the rule of law in a cohesive society with more or less active members—to ensure the well-being of citizens or particular groups of citizens and residents (cf. Vabo & Szebehely, 2012). This move beyond a focus on the state alone is important given all the possible combinations of approaches to and organization of welfare and the ways that responsibility for different elements can be assigned to different parts of this societal configuration. However, it is through collective action and decision-making that such delegation becomes legitimate. Agriculture—today part of the super-national EU common-pool-resources-­ institution CAP—was a case in point early on and prepared the ground for the later regulation of other domestic markets. Thus, the Swedish welfare state consists of a number of specific welfare common-pool-resources-institutions and policy arenas. The power structure is primarily rooted in the institutionalized class divisions and interests generated by the advent of capitalism and popular social mobilization in the late nineteenth century. Movement and party identification is still basically anchored in the social stratification of Swedish society in particular with large sections of female white-collar employee usually voting centre-left in support of welfare state initiatives and institutions. Although farmers are numerically marginal today, their role in electoral politics is still crucial to an understanding of Swedish welfare state development especially in the formative years but also during the restructuring in the 1990s, when an informal coalition between social democrats and the Centre party prevented a financial collapse and blatant austerity, or “neo-­ liberalism”. It was also in that decade that new parties appeared on the political stage: Christian democrats on the right and Greens on the left of centre, at the same time as the Communists after a drawn-out process became the Left party. Moreover, right-wing populist movements and parties finally entered Parliament in 2010 through Sweden Democrats (since 2014 Sweden’s third largest political party), although there was a brief episode in 1991–1994 by a forerunner, New Democracy. Finally, the feminist movement has tried to challenge the existing political order, so far unsuccessfully thoroughly penetrating the established political parties including the newcomers. From the 1990s, the establishment of pensioner parties has been attempted, albeit unsuccessfully so far on the national level but while existing in a few municipalities. However, in recent decades the process of interest articulation has gone beyond conventional corporatist conflict configuration of pure party politics, agriculture and the labour market, and the old popular movements. Hence, the logic of collective action is still applicable to most sectors of society, and voluntary national associations with regional and local branches, often with access to governmental financial sources, have mushroomed in the open spaces of civil society. Thus, the organizations of the elderly and disabled are a case in point to which I shall return further on in this article.

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

79

Moreover, of outmost importance is the division of labour and power between the central and local levels with the municipalities and county councils as significant providers of welfare services. Local elections can, thus, be almost as crucial as national. While financing—tax collection—is administratively centralized, the municipalities and county councils have the right to levy taxes on income to be able to provide legislated welfare services including education of children. Health policy is also decentralized to the county council under a national legal framework, and local authorities—the municipalities—are in charge of personal social services to families, disabled and the elderly. In the most recent decades, though, contracting-­ out and tax-financed voucher systems have paved the way for significant privatization of welfare services. But income maintenance including pension policy is still a central state arena albeit somewhat diluted in recent decades. Here, private high finance has strengthened its position in recent decades. However, total social spending amounts to roughly 30% of GDP of which half is spent on welfare services by local government and the other half on income maintenance of which pensions take half (or a quarter of the total). Firmly within these parameters, in 2006 after 12 consecutive years of social democratic cabinets, and almost 70 out of the last 85, a new centre-right four-party coalition, the “Alliance” led by the Moderates (formerly the Conservative party) took over the helm. In the general election of 2014, this government lost out to another minority “red-green” government again under social democratic premiership. The next elections are scheduled for September 2018; suffice to add before turning to the social programmes—the mechanisms of the normative foundations—of the central and local welfare state.

5.4  R  etirement Pensions, Personal Health and Social Services and Housing as a Key Common-Pool-Resources-­ Institutions in a Capitalist Market Economy In what follows is an overview of the main social programmes directed at the aged in Sweden from income security via health and medical services to housing and home help. First, retirement pensions: from the 1880s, old age pensions became a part and parcel of solutions to the new social or workers’ issue. Long before the idea of a generational contract came into force, in Sweden the first national pension programme saw the light of day in 1913. The idea of social insurance had been imported from Imperial Germany and was adapted to local conditions of rural smallholding and poverty. Inspiration came from neighbouring Denmark where a near-universal municipal programme had been introduced in the 1890s. In Sweden, the proposal to Parliament came from a Social Liberal Government but was supported social conservatives as well as social democrats. It was a meagre programme but of some significance for those who had never had an independent monetary income, mostly women aged 67+ who now got the right to claim a benefit on their own—as a social right still couched in the language of duties and obligations—irrespective of the

80

S. E. O. Hort

financial position or status of their eventual husband or head of household. In this way, the burden of poor relief would be transferred from the local authorities to the central state. The set-up accordingly reflected the ongoing social transformation of a poorhouse of Europe to a modern industrial capitalist society with an emerging mobilized and organized working class. Half a century later, two major pension reforms temporarily solved the problem that the earlier solution had left unresolved. The basic pension programme from 1948 took pensioners off the poor-relief rolls (at a time when poor-relief recipients finally got the right to vote) and 12 years later a compulsory earnings-related supplementary pension programme financed with a payroll tax combined with an income supplement for those it did not include laid the foundation for three decades of steadily growing affluence among the elderly. On top of the compulsory two-tier programmes the labour market organizations—trade unions and employer associations—negotiated occupational pension plans for most sectors and employees. Moreover, tax deductions enabled a fourth layer of private pension insurance for individual savers that became fairly popular from the 1980s. Right from the start of the two-tier statutory system and reflecting the power balance at the time, there were those who warned of the financial consequences of such generosity, but it was not until the global neo-liberal surge after the fall of the Berlin Wall and the deep local recession of the 1990s, social democracy being out of power for three consecutive years 1991–1994, the main political parties and the main labour market organizations reached an agreement which transformed the compulsory pension system from a defined-benefit to a quasi-defined-contribution system. With the mid-1990s pension package, Sweden led the way towards privatizing social security, or so it seemed. The new compulsory system is still maturing, and not until 2020 will the system be fully implemented. Thus it is too early to make a definite evaluation of its outcome (cf. Birnbaum, Ferrarini, Nelson, & Palme, 2017; also Ahn & Olsson-Hort, 2003). However, a substantial part of pension benefit is no longer to be calculated regardless of earnings and work period. The former basic tier will more or less disappear although what at present looks like a rather ungenerous guarantee benefit will be available for those with 40 years residence and no means of support. The best 15 years in the former second-tier superannuation scheme benefitting females with a brief employment record has been replaced by continuous contributions over a working period of 45 years. Thus, the universal right to a state pension will be geared to gainful employment or other business activities such as self-employment. The pressure from intergenerational redistribution will be offset by an as yet rather unknown regulatory “demogrant” which during periods of weak or no economic growth will reduce the burden on the active generation, or decrease the generosity of the system. Another significant characteristic of the new statutory programme is that a minor part of each year’s contribution is set aside for individual risk investment. This instrument made the change in Sweden interesting to Wall Street and other global investors. In Sweden, each insured person (the gainfully employed or otherwise economically active under the age of 65) has the opportunity to save a certain amount in some of the 600 private funds that are operated by merchant banks and insurance companies including those jointly owned by the labour market “social partners” and those solely owned by or associated with the trade

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

81

union movement. This investment is the responsibility of the individual; there is no pooling risk apart from a state-run fund for those who opt out that is, those who do not take advantage of the freedom of choice, roughly one in four of those concerned when the system was introduced. It is only fair to say that to date commercial finance has not failed the majority of Swedish pension savers, but stock exchange ups and downs have left their mark and there is obviously no guarantee that this will not happen. After almost 20 years this could be lull before the storm? Second, personal social service for the elderly: in the distant past, people living on their own have tended to rely on outside support to continue to do so as they age. Such services have been provided most frequently by family members and other close relatives. The well-to-do also had domestic servants. From early last century, the municipalities tried to overcome the poorhouse dilemma by erecting homes for the elderly. However, this was a painful process that lasted well into the 1960s although new measures were taken from the late 1940s onwards (Edebalk, 2016). Service homes with an increasing degree of independent living and home help services for the less frail supplemented more outdated forms of support. Nevertheless, an increasing number of oldest old accentuated the pressure on public provisions including hospital services. In the 1990s, public care of the elderly changed appreciably. Responsibility for nursing homes and for patients who still needed care after medical treatment was transferred from regional county councils to the local level, the municipalities, in 1992. Nevertheless, the burden on the county council medical care system grew as a distinct increase in the number of elderly people coincided with a reduced supply of hospital beds. The municipalities generally reacted by tightening assessments of need, and according priority to needs that were particularly great. A growing proportion of resources went to the needy groups, while slightly more better off elderly persons who had previously been recipients now either turned to relatives or purchased private services. The coverage of services in the home was reduced in particular, accompanied by more hours of assistance for the remaining recipients. In the most recent decades, recipients of services in the home are considerably older and need more care than before. The situation varies more between municipalities. Moreover, the municipalities have increased the fees paid by care recipients and there has been a growing tendency to relate fees to income. As a consequence, persons with a relatively large pension and a moderate need of help have turned to the private market instead. Retrospective assessments of the 1992 reform have found shortcomings in various forms of municipal care as well as in the links between hospital care and care at home. Most studies indicate that even elderly people living on their own often have close contacts with their family and the neighbourhood and generally receive substantial informal support from relatives, friends and neighbours. As mentioned, most pensioners live by themselves or with their spouse in their own home. However, people who need support in their day-to-day existence have the right to claim assistance if their need “cannot be met in any other way”, to cite the existing National Social Services Act. For instance, during the last decade in some municipalities relatives have been able to become municipally funded service providers, family carers, including a wife who cares for her frail husband. In some cases other family members can be employed by the

82

S. E. O. Hort

municipality and in others the elderly person in need of assistance can obtain a grant to pay a family member for providing the care. Third, personal medical services: health policy is a national priority albeit funded predominantly from taxation throughout the twentieth century and still into the present. It is the regional government (county council)—in legal terms on an equal footing with the local authorities (municipalities)—that has had and still has the overall responsibility for providing medical treatment and care (Riksrevisionen, 2014; Statskontoret, 2015). Guided by national recommendations and already from the late 1950s central government incentives health services and in particular the inpatient hospital system were modernized and rapidly expanded throughout the country. Somewhat later a major national programme was launched to build up outpatient preventive health clinics and ease the pressures on the more expensive inpatient services. A reform in the late 1960s introduced a still existing uniform fee and in practice nationalized the health sector making most doctors either county council employees or holders of contracts with the National Sickness Insurance Fund. Health expenditures which from 1960 to 1980 rose from 3 to 9% of GDP have in the twenty-first century risen to 11%. The elderly were among the first groups to suffer from welfare state cutbacks: pensioner’s “free year” of hospital care had already been eliminated in the 1980s. Furthermore, in the 1990s private initiatives again gained ground though largely still financed from public funds, following legislative changes at the national level. Outpatient clinics were either sold or contracted out by county councils first by local authorities where the political majority was non-social democratic but later as part of bipartisan agreements all over the country. Particularly after the shift to a non-social democratic national government in 2006 some hospitals have been privatized but this is still a bone of contention between the right and the left in Sweden. The return of the social democrats to power in 2014 slowed down the privatizing trend. There is naturally a strong correlation between age and health problems, although overall health has improved among the elderly with increasing longevity. Among the oldest old however, the prevalence of illness is rising. Large segments of these cohorts are for instance visually disabled (some 250,000 among the over 65 s), have hearing problems (some 500,000) or other obstacles to participation in everyday activities. They are frequent consumers of medical care and services including pharmaceutical products. Although these groups constitute a small minority of the total population, their share of total health costs has been estimated to well above 10%. The elderly, not to mention the oldest old, have been obvious beneficiaries of the modern medical care system. The demographic expansion of this age group was also the main reason behind the complete redirection of health care policy and the transition from institution-­building to mobile services which has had a profound impact for the very old in particular care shifts from hospitals to home. Studies indicate a strong potential for improved rehabilitation the sooner the patient leave the hospital. Nevertheless, for decades this system has had drawbacks for these elder. In particular the elderly have suffered from lengthening waiting lists for lighter and shorter hospital treatment. More important, however, is long-term geriatric care, where inpatient health services have not always lived up to expectations and promises. Despite the

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

83

t­remendous increase in home health care in the last three decades, the co-existence of the two types of local government (county councils and municipalities) has contributed to the continuation of organizational problems in transferring patients from intensive-­care to intermediary nursing homes and care in homes for the elderly due (cf. Björk, 2013; Statskontoret, 2016). Fourth, the constitutional social right to shelter: in Sweden, a majority of the elderly population has had homes of their own throughout the modern era. In rural areas there were those who lived next to kin in a house set aside for the retired couple, the widow or widower, while an even smaller group spent old age in their children’s homes. For those without means or family local authorities were obliged to provide shelter either in the home of a better-off person (auctioned out) or in a poorhouse. Towards the end of the nineteenth century new forms of institutional residency arose inspired by some of the guild’s homes for elderly members or family members as urbanization spread. From the 1920s separate social housing for the elderly became an alternative to the poorhouses which in addition to the old and poor often contained a strange blend of insane adults and orphaned children. County councils expanded psychiatric care for instance by setting up special wards for the demented. The state encouraged municipal authorities to build homes for elderly people in need of special services; later on the growth of public resources led to more independent service houses. Right up to the 1970s, as already mentioned the bulk of this expansion concerned the building of institutions. With the expansion of long-term medical care and old people’s homes the elderly were looked after in institutions to a much greater extent than previously. One important factor behind this was the relatively poor housing condition of elderly persons living on their own. Another was the queue for places in institutions that resulted from the growing number of elderly people. Parallel to these developments, the state launched a major universal programme to upgrade and expand the housing stock. This occurred in three or four waves from the 1930s up to the late 1980s; the urban “Myrdal houses” and a rural housing improvement programme in the 1930s, the early postwar urban housing programme, the multi-dwelling million apartments programme in the mid-­1960s, and the interest-subsidized expansion of single-family housing in the late 1970s and 1980s. Furthermore, rents have been regulated since 1942. The elderly benefitted from all this and so did those who became old during this period. From the 1970s almost all forms of institutional residency have been constantly criticized and new policies have been developed stressing independent living and enabling older people to live on their own with a high quality of life. People should be able to grow old in security, be treated with respect, retain their independence, be able to lead active lives and as senior citizens exert an influence on society and their everyday life. An accessible society, good housing, transport services and various home help services are examples of important ways of realizing such a programme. Thus, one of the most important principles of Swedish policy for the elderly is that public resources should be framed in such a way that older people can continue to live in their own homes for as long as possible, even when they need extensive medical and social care. For those who for some reason cannot live at home, short-stay housing is available nowadays for rehabilitation for instance after

84

S. E. O. Hort

a period in hospital. For those who are permanently unable to live at home there is group housing for dementia as well as nursing homes though scarcity prevails. More recently the municipalities have stressed the provision of support for private housing for the elderly or for improving general social housing for this group. The municipalities provide grants for certain measures to enable disabled persons to use their homes more efficiently. Grants for housing adaptation enable elderly persons with disabilities to make the changes to their homes that are needed for them to go on living there. Home-care services can be offered round the clock, which means that even persons with an extensive need of health care can remain on their own home. Elderly people are increasingly living at home up the end of their lives, and even the severely ill receive medical and social care in the home. Common adaptations include removing thresholds and rebuilding bathrooms. There is no cap on such costs and grants cover the entire reconstruction, regardless of the applicant’s income. Moreover, elderly and disabled persons can obtain personal safety alarms connected to a service unit. Those who cannot use regular public transport are entitled to transportation services usually in the form of a taxi but sometimes special vehicles are available. Users who need to travel outside the orbit of the local transportation services, for instance for family reasons can be approved for national transportation assistance by the National Social Insurance Office. In 2015 well over 90% of the elderly are living at home with or without home-care services. Nowadays, housing conditions for the elderly do not differ significantly from the general population’s and the general standard of housing is high (Trygdegård, 2017). In recent decades private as well as public housing and construction companies have invested in high-quality independent senior living intended and adapted for couples and singles aged 50+. With growing affluence among the elderly this has also become an attract alternative for many non-seniors with an eye to the future. Likewise, those who have been tenants in attractive areas particularly in the metropolitan regions have most often benefitted from the sell-out of public housing.

5.5  M  obilizing Elderly People Through Voluntary Civil Society Associations At the start of this article it was questioned whether the elderly and disabled are a true historical subject of social change and transformation. The elderly have been treated as customers and users of private and public services lacking sufficient power resources in relation to market and state. With fairly generous public and private pension schemes, have the elderly become vital to the overall functioning of the mass consumption economy able to exert an influence on state, economy and society? Moreover, with increasing numbers of elderly in a modern organized society, have they coalesced into something new and different; have they for instance transcended barriers in much the same way as certain feminists claim that women have done and what theorists of whiteness propose regarding peoples of colour? Has the emergence of strong mobilized interests of pensioners changed the social

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

85

relationship and interdependency between this social category and other powerful actors and institutions? Has the welfare state produced its own gravediggers, a leisured “identity” category insatiably demanding more and more for ever-more? These are questions to be posed with the emergence of the so far largest generation of recently retired people, young elders, the baby-boomers of the 1940s and early 1950s. Many of the over two million elderly people in Sweden find their way into the voluntary social organizations of retired people where they take part in regular everyday activities such as excursions, choir singing and study circles (Hort, 2009). Roughly every second pensioner is a member of one of the five national associations of retired Swedes doing politics at the national and local levels of government. The largest is PRO—the National Organization of Pensioners—closely linked to the social democratic working class movement and often chaired, nationally and locally by former political heavyweights. In 2017, some 400,000 persons belong to this organization with local branches all over Sweden. Alongside the trade unions, PRO is nowadays perhaps the most vital part of the working class movement with more people actively involved than in the party itself. Second to PRO is SPF—Swedish pensioner’s association—which today is the joint venture of the non-socialist parties for elderly Swedes with some 250,000 members. For a brief period—the Stalingrad turning point of the Second World War—this organization posed a communist challenge to the Swedish working class movement’s dominant party—but over the decades it has moved to the right of the political spectrum without actually aligning with one or the other non-socialist party. In the past decade, this association has been chaired at national level both by former Moderate, Centre and Liberal MPs while the local picture is even more mixed with former Christian democrat municipal politicians also in leadership positions. Of the other three national pension associations the largest, with well over 100,000 members, is based on local government employment. The next largest has its origins in central government employment but since 1994 it is open to all pensioners. It is perhaps the most confrontational of the five, fighting the rights of pensioners against the central state in legal battles in the courts as well as on the streets with a high degree of legitimacy. The smallest is a religious association close to the Swedish Church but, being ecumenical, it has more local branches than the next smallest. It is less combative than the others but participates with them in joint political actions. Between them, these three have more than 200,000 members. Thus, there are clear links to the various levels and forms of state-society institutions. Furthermore, membership definitely overlaps, though perhaps less than one might expect. But their total membership does point to a growing aggregation of interest. True, the members of these associations of retired people are beneficiaries of welfare programmes and unable to refuse benefits such as pensions as it is their means of subsistence and survival, their livelihood. However they are also voters and have links to their previous organizational interests. Political parties are in dire need of them to hold office after successful elections. In addition, in a competitive consumer culture such associations are able to attract positive media attention to the demands of dependent and deserving pensioners and loyal taxpayers. In the

86

S. E. O. Hort

twenty-­first century, moreover, such organizations have employees who possess expert knowledge across a broad field of social policies. They can also obtain the backing of organizations for the disabled, which have likewise grown in recent decades. Since the 1970s, at local government level there are pensioner councils, an arena for consultation and discussion consisting of representatives of the organizations of pensioners and municipal politicians. Sometimes moreover, elected members of local authorities are supported by municipally employed personal. Such Senior Citizen’s Councils accordingly vary from one local authority to another but nowadays exist in almost every municipality (as mentioned some 300) although there is no national law requiring them. The 20-something county councils have similar consultative organs. Some local pensioner councils were established after pressure from local organizations of retired people, while others were deemed necessary and initiated by imitating local authorities. Moreover, such councils have been created after pressure from national organizations of retired people. Nevertheless, the presence of retired people in the elected representative organs of the local and central state—Parliament as well as municipal and county councils—is striking, less than a handful 65+ in the outgoing 2018 national Parliament. At the end of 44 years of almost uninterrupted social democratic government, the PRO national congress in 1973 demanded a right of negotiation and reiterated this demand in discussions with governments of various colours in the 1970s and 1980s (in the period 1976–1982 there were four different non-social democratic cabinets). In 1987, the Government appointed a Commission of Inquiry to investigate the political influence of pensioners, which in 1991 led to the establishment of a national pensioner forum for deliberations between the central government and the national interest organizations of pensioners. Since then, regular meetings have been held four times a year between representatives of the national associations and the Minister of Social Affairs and her close colleagues from the civil service (for instance the Director-General of the Social Insurance Office). In addition, the chairpersons of the associations meet the Prime Minister once a year for political deliberations. Thus, from the 1990s the organizations of retired people gradually managed to get a say on political issues that they considered to be vital such as pensions, health and taxation. In the 2018 election, an increase in the n­ umbers of elderly voters is expected to significantly alter this group’s weight of power. In advance, this became visible in the outgoing government’s 2017 proposal to lower taxation on retirement income. But few 65+ will probably enter Parliament after the election in 2018 despite a growing spotlight on the elderly before Election Day.

5.6  M  ass Consumption and/or Public Policy: Concluding Remarks Mass consumption is a major characteristic of Western societies including contemporary Scandinavian welfare states where even their (mass) politics is on the way turning into a mode of consumption (cf. Widerberg, 2017). In the twenty-first

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

87

century, China is also on the path towards a society of conspicuous consumption similar to Japan and Korea, maybe also the United States of America. In the West as well as in the new East, pensioners are also important as customers and consumers in their own right but also through the intergenerational redistribution from older to younger people within families, from in particular grandparents to grandchildren with or without parents as intermediaries. Family bonding can be as strong in a modern secular society as in an overwhelmingly religious and traditional, partly because of independent living (Göransson & Widerberg, 2016). Furthermore, the elderly are larger customers of pharmaceutical products than the majority of the population. Otherwise they do not differ at all that much from other child-free households except that they have time to shop when others do not. Hence, the elderly have become an important target group for advertising and market research. Moreover, there is one product that other consumers tend to disregard: the funeral. An end in decency and dignity is an aspect of human life that most often tends to be passed by in silence by the literature on aging, the elderly and the welfare state. Only the gods know why? Each year some 100,000 Swedes pass away. The number is tending to rise as society ages, though it is being held back by increasing longevity. Terminal medical care in Sweden is part of the welfare state’s medical health package but funerals are not. Literally speaking, the Swedish welfare state is no cradle-to-grave arrangement, though the former Lutheran State Church, now the voluntary protestant Swedish Church, takes on a heavy tax-funded responsibility. In general funerals occur in churches or other religious buildings presided over by a priest or religious leader. With the increasing ethnic diversity of the Swedish population, non-protestant churches and other religious societies have come to play a larger role at the end of life as well as in general. There is also a minority of secular ceremonies. After the funeral in most cases the corpse is taken to the graveyard, either directly or via a crematorium. Most cemeteries are under the auspices of the Swedish Church, but some of the other religious associations have private grounds. In the big cities nowadays for instance Catholic, Orthodox, Jewish and Muslim communities have their own cemeteries. Such places are important meeting-points for mourners; above all in the big cities they are often perceived as monuments to the past. The organization of funerals is, however, in the hands of private or cooperative entrepreneurs—morticians or undertakers—and the cost is covered in the majority of cases by the deceased’s estate or by relatives. From a social service perspective, there is an obligation to pay for those who lack means and supportive relatives, however, their number is negligible and no official statistics are published by municipalities or Statistics Sweden. The latter does still publish statistics on friendly funeral societies because they were a part of the sickness insurance movement while it is the undertaker business that provides market figures. Each year some one billion Swedish kronor, roughly 100 million euro, are spent on funeral ceremonies, coffins, flowers, etc., and some 2000 people are employed in this business (not including the religious staff). The structure of this industry to some extent reflects Swedish society. Local private undertakers spread all over the country and organized in the National Association of Undertakers have slightly more than half of the

88

S. E. O. Hort

market. A good third of the market belongs to the cooperative Fonus, founded in 1945 and de facto an outlet of the Swedish social democratic working class movement. Fonus also operate a coffin factory in Sweden with an annual output of some 35,000 wooden caskets. The largest of the organizations of retired people (PRO) is represented on the board of Fonus. To end, aging—the loss of work capacity and the threat of poverty—as a social phenomenon has haunted the Welfare State since its inception. So also in Sweden where many attempts have been made to come to terms with this living ghost with a view to creating and, in recent decades, de- and reconstructing a Welfare State. Above, I hinted at the possibility of the emergence of a new historical subject in the open spaces of civil society, the appearance of the so far largest generation of retirees, within or outside the boundaries of organized interests of retired people. Experienced, healthy and economically relative secure, no longer chained to the buyers of labour power, this generation may have the opportunity to take unforeseen and create not yet thinkable steps. Aging was shorthand for the loss of individual earning capacity reflecting the general decline of the human body and mind—the prospect of death—which also impacted other aspects of life and social relations. At present, though, in many of its shapes, at least in Sweden this phantom still seems to be sleeping. Nevertheless, there are those who pose the hard questions and point out the challenges ahead for the elderly as well as for society and state. Older Swedes are healthier than at any time in history. Thus, in the second decade of the new Millennium, the most crucial issue of aging—human economic and social security or “pensions”—seems to have been “solved” for the time being, although the organized interests of retired people are doing their best to pursue this issue at a time when 15% or some 300,000 of the elderly are estimated by their representative associations to be relatively poor. Recently, such pressure has partly been successful through the government’s proposal to eliminate the extra tax on retirement income instituted in 2007. It should be remembered that the reaction from the organizations of retired people was not long in coming, when the government at the time lowered taxes for working people but not for those who have retired with a considerable work record behind them. The five national associations including the one close to the non-socialist parties in government issued a joint statement asking for compensation but were met by stern response from the ruling coalition. The social democratic leadership in opposition responded favourably but it took almost 4 years at the helm for them to act. But the organizations of pensioners managed to galvanize internal as well as external support for their demands not to be forgotten. Most importantly, the national associations of retired people have not yet taken up the challenge posed by global developments, in particular a UN-inspired ­proposal put forward by the Grand Plan for a Global Pension. Compared with the financial outcome of “a-dollar-a-day” the demands of the national associations are actually less beneficial for the latter. Thus, going international would improve the situation of pensioners even in one of the most developed welfare state. There is some reason to believe that in an optimistic scenario the social generations of the 1940s and 1950s—generations that has experienced rapidly increasing prosperity as well as major social upheavals, temporary victories as well as long-lasting defeats but also

5  Sweden: Aging Welfare and Social Policy in the Twenty-First Century

89

the possibility of human emancipation—will rally not only in Sweden behind a solution that goes beyond national borders. This is a global social generation with hard-won organizational experience from Berkeley to Saigon, from Mexico City to Paris, Prague and Berlin. The Scandinavian experience was more peripheral, though not far from centre-stage. The generational emphasis was perhaps more on institution-building than on spontaneous movements. Although there have been spatial competition, it is a generation that has not lost touch with its offspring but fought for a more inclusive child-friendly society. This social generation is turning greyer by the day. In the decades to come it may surprise most grand theorists of social change by shifting the historical subject from yesterday’s adorned youth to post-work adults banging on death’s door. Hence, in this modest optimism of intelligence, a new historical subject is waiting in the wings, the gracefully older with the societal movements and popular organizations of the universal welfare state acting as midwife in a civilizing process. As emphasized from the start of this article the object of government in peace and war is not the glory of rulers or races, but the happiness of common women and men. Or, as a famous saying goes, for those who will come after, the gateway to the future—posterity—can only be unlocked by the past.

References Ahn, S. H., & Olsson-Hort, S. (2003). The welfare state in Sweden. In C. Aspalter (Ed.), Welfare capitalism around the word. Hong Kong: Casa Verde. Alestalo, M., Hort, S. E. O., & Kuhnle, S. (2017). The Nordic model: Conditions, origins, outcomes, lessons. In S. Kuhnle, Y. Otsuka, A. Kamiko, P. Kettunen, & K. Pedersen (Eds.), Sustainable welfare - The Nordic experience. Osaka: Ritsumeikan University Press. (in Japanese). Beveridge, W. (1942). Social insurance and allied services. London: His Majesty’s Stationary Office. Birnbaum, S., Ferrarini, T., Nelson, K., & Palme, J. (2017). The generational welfare contract – Justice, institutions and outcomes. Cheltenham: Edward Elgar. Björk, L. (2013). Conceptualizing managerial work in local government organizations. Göteborg: University of Gothenburg, Göteborg Studies in Work Science. Chang, K.-S. (2016). Post-socialist class politics with Chinese characteristics. In G. Olofsson & S. E. O. Hort (Eds.), Class, sex and revolutions: Göran therborn – A critical appraisal. Lund: Arkiv. Edebalk, P.-G. (2016). Socialminister gunnar sträng. In P. Bergman & G. Olofsson (Eds.), Påväg. Lund: Arkiv. Göransson, A., & Widerberg, K. (2016). Göran between sex and power. In G. Olofsson & S. E. O. Hort (Eds.), Class, sex and revolutions: Göran therborn – A critical appraisal. Lund: Arkiv. Hort, S. E. O. (2009). Aging and the welfare state in Sweden. In A. Walker & C. Aspalter (Eds.), Securing the future for old age in Europe. Hong Kong: Casa Verde. Hort, S. E. O. (2014). Social policy and welfare state in Sweden (Vol. I & II). Lund: Arkiv. Hort, S. E. O. (2015). Towards a modern social welfare formation? Korean Journal of Sociology, 49(6), 63–86. Hort, S. E. O. (2018). From social Europe to the Nordic welfare model: Still social democratic – Or neo-liberal; neo-conservative? Lecture given at Swedish Institute in Athens (SIA), Athens, Greece, April 19, 2018.

90

S. E. O. Hort

Hort, S. E. O., Kings, L., & Kravchenko, Z. (2016). Still awaiting the storm? The Swedish welfare state after the latest crisis. In K. Schubert, P. de Villota, & J. Klugmann (Eds.), Challenges to the European welfare systems. Heidelberg: Springer. Kuhnle, S. (2017). Fellesnordisk inspirasjon for velferdspolitikk i verden. In P.  Bergman & G. Olofsson (Eds.), Påväg. Lund: Arkiv. Kuhnle, S., & Sanders, A. (2010). The emergence of the Western welfare state. In F.  Castles, S. Leibfried, J. Lewis, H. Obinger, & C. Pierson (Eds.), The Oxford handbook of the welfare state. Oxford: Oxford University Press. Lundberg, S., & Månsson, S.-A. (2017). Demonstranter på väg? Lång väg från 1968…. In P. Bergman & G. Olofsson (Eds.), Påväg. Lund: Arkiv. Persson, G., & Sharp, P. (2015). An economic history of Europe  – knowledge, institutions and growth, 600 to the present (2nd ed.). Cambridge: Cambridge University Press. Renswick, C. (2017). Bread for all: The origins of the welfare state. London: Allen Lane. Riksrevisionen. (2014). Överensko9mmelser mellan regeringen och SKL inom hälso- och sjukvården  – frivilligt att delta men svårt tacka nej. Stockholm: Riksrevisionen. (Report 2014:20). Rothstein, B. (2015). The Chinese paradox of high growth and low quality of government: The cadre organization versus max weber. Governance: An International Journal of Policy, Administration and Institutions, 28(4), 533–548. Statskontoret. (2015). Sammanhållen vård och omsorg om de mest sjuka äldre. Stockholm: Statskontoret. (Report 2015:18). Statskontoret. (2016). Ökad bemanning inom äldreomsorgen. Stockholm: Statskontoret. (Report 27). Svallfors, S. (2013). Government quality, egalitarianism, and attitudes to taxes and social spending: A European comparison. European Political Science Review, 5(3), 363–380. Therborn, G. (2014). The killing fields of inequality. London: Sage. Törnqvist, O. (2017). Reinventing social democratic development: Insights from Indian and scandinavian comparisons. Copenhagen: NIAS. Trygdegård, G.-B. (2017). De äldre och välfärden. In H. Swärd (Ed.), Den kantstötta välfärden. Lund: Studentlitteratur. UN. (2017). World population prospects: The 2017 revision. New  York: UN Department of Economic and Social Affairs. Vabo, M., & Szebehely, M. (2012). A caring state for all elderly people. In A. Anttonen, L. Häikiö, & K. Stefánson (Eds.), Welfare state, universalism and diversity. Cheltenham: Edward Elgar. Widerberg, K. (2017). Folkhemmet som kommers – IKEA. In P. Bergman & G. Olofsson (Eds.), Påväg. Lund: Arkiv.

Chapter 6

Looking for the Easy Way Out: Demographic Panic and the Twists and Turns of Long-Term Care Policy in Finland Teppo Kröger

6.1  Introduction Long-term care policy of Finland is a paradox: on the one hand, Finland has been one of the first nations to start building modern home-based care services for older people and Finnish policy is still officially adhered to the Nordic welfare model and its universalist aspirations but, on the other hand, Finnish provisions have remained below the general Nordic level and, especially since the beginning of the 1990s, policy development in Finland has been characterised by the central state’s constant avoidance of responsibility. The key features of the Nordic welfare model have included generosity in benefits and services as well as universalism, that is, the objective to cover with provisions all population groups, not just disadvantaged or impoverished families and individuals (Anttonen, 2002; Kröger, Anttonen, & Sipilä, 2003). Public services are expected not only to be available to but also actually used by middle- and high-­ income groups, which means that the services need to be attractive and good enough (Szebehely & Meagher,  2018). Accordingly, high-quality and widely accessible social and health care services have been seen to be a key characteristic of the Nordic welfare model, captured in the term ‘social service state’, distinguished from Central European ‘social insurance states’ (Anttonen, 1990; Sipilä, 1997). Nordic countries have been pathbreakers in various areas of care policy and they have been early also to develop home care services for older people (Szebehely, 2003). Finland, too, put up legislation already in 1966 to build universalist ‘home help’ provisions for older people (Rauhala, 1996). Alternatives were needed for traditional residential care at a time when rapidly increasing female employment questioned the overwhelmingly informal model of providing care for people in old

T. Kröger (*) Department of Social Sciences and Philosophy, University of Jyväskylä, Jyväskylä, Finland e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_6

91

92

T. Kröger

age. Like in the case of other social and health care services, the task to construct home care services was in Finland given to municipalities that, though being officially self-governing entities, were from the late 1960s to late 1980s under detailed central regulation. In addition to central control, the state used generous central grants to prompt local authorities to build up a rather uniform service system all around the country. This implementation model was a success and, by the end of the 1980s, Finland was offering home-based care to a larger part of its older population than almost any other country (Kröger, 1997, 2011a). However, this positive development was halted by the advent of the 1990s. During the 1990s, home care underwent a radical transformation (Kröger & Leinonen, 2012). Coverage levels dropped dramatically and many older people were excluded from publicly funded home care provisions and had to rely on their family members. The changes represented decreasing public responsibility for the needs of the older population but they took place without any real policy debate or major modification in legislation. Since the mid-1990s, Finland has also experienced widespread outsourcing of municipal care services to for-profit providers, accompanied by increasing out-of-pocket use of private care provisions that has been supported by a new tax rebate scheme (Anttonen & Karsio, 2017; Karsio & Anttonen, 2013; Mathew Puthenparambil & Kröger, 2016). The emergence and continuous growth of the for-profit sector in long-term care has transformed the earlier model that used to be dominated by public provisions. The development has also raised concern about increasing inequalities in the access to and use of long-­ term care. By the late 2010s, Finnish care provisions have come quite far from the centrally regulated public provision model of the 1980s. This chapter aims to map the twists and turns in the development of long-term care (LTC) in Finland since the start of the 1990s. Various policy changes have taken place during the last three decades. The main argument of the chapter is that these changes have to a large part been motivated by what is called here ‘demographic panic’, that is, fear of consequences of population ageing to the public purse. Since the late 1980s, Finnish long-term care policies have been made under the shadow of the ‘demographic time bomb’ discourse that argues that care expenditures are to rise exponentially if determined action is not taken to curb the expenditures (see Mullan, 2000; Vincent, 1996). As a result, the focus of policy has been on preventing the increase of the costs, not on developing care provisions that are needed by the growing older population. Before taking these policy turns under closer examination, key statistics concerning development of the age structure as well as the use of main care provisions in Finland are presented.

6.2  Age Structure of the Population and Use of Care Services During the last decades, the population of Finland has been ageing rather fast and the trend is projected to continue until the 2060s (Table 6.1). In particular, the oldest age groups have been growing the most. In 1990, 5.6% of the population were

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

93

Table 6.1  The size of 75+ age groups in Finland, 1990–2065 (% of total population)a Year 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 2065

Age 75–79 2.8 2.7 3.2 3.4 3.3 3.6 4.2 5.7 5.3 5.2 5.3 5.1 4.7 5.2 5.5 5.5

80–84 1.8 1.9 1.9 2.4 2.6 2.6 2.9 3.5 4.8 4.6 4.6 4.7 4.5 4.3 4.8 5.1

85+ 1.0 1.3 1.5 1.7 2.1 2.5 2.8 3.1 3.8 5.2 5.9 6.2 6.6 6.7 6.7 7.1

Total 5.6 5.9 6.6 7.5 8.0 8.7 9.9 12.3 13.9 15.0 15.8 16.0 15.8 16.2 17.0 17.7

Source: Statistics Finland (2018) (StatFin data bank) a Figures for 2020–2065 are projections

75 years or older but in 2015 this share was already 8.7%. This change can be characterised as modest but at the same time the share of the oldest 85+ age group has more than doubled. Ageing is expected to further accelerate in Finland. By 2040, 15.8% are estimated to be at the age of 75 or over. Once again, 85+ is the age group that is projected to grow fastest, covering 5.9% of the total population by 2040. However, when looking at the projection for another 25 years, population ageing is estimated to slow down considerably. From 2040 to 2065, the size of the Finnish 75+ group is expected to rise only by 2% points from 15.8 to 17.7. Not even the share of the oldest old is estimated to grow rapidly during this period: in 2060, 7.1% of the population in Finland is expected to be 85 years or older. Long-term projections of the population structure are always difficult to make and they are based on a number of presumptions. The development of the birth rate affects the age structure and at the moment it is on a negative course in Finland, which might mean that younger age groups remain smaller and, thus, older age groups relatively larger than expected. On the other hand, at the moment the number of people born outside Finland is very small within the population, which is however very likely to change during coming decades. As an increase in immigration usually increases the share of younger age groups, ageing of the Finnish population might consequently be slower than currently anticipated. Without doubt, the Finnish population has been ageing recently and especially the size of the oldest 85+ age group has increased and will continue to increase— and it is this age group in particular who have care needs. How have long-term care provisions been able to respond to population ageing in Finland?

94

T. Kröger

Looking at long-term care statistics, institutional care can be seen to have experienced a major scaling down and transformation during the period from 1990 to 2015 (Table 6.2). In 1990, 7.8% of the 75+ population were living in traditional social care homes and another 3.4% in nursing homes provided by local health care authorities. In 25 years these two services that used to be the foundation of long-­term care in Finland have almost vanished. In 2015, only 1.7% were using care homes and 0.4% nursing homes. Together they covered only 2.1% of the age group, while 25 years earlier 11.2% of the age group had used their residential provisions.

Table 6.2  Use of local authority funded care services among the 75+ population in Finland, 1990–2015 (% of age group)

Year 1990 1995 2000 2005 2010 2015

Care homes 7.8 6.5 5.3 4.3 3.2 1.7

Nursing homes 3.4 3.4 3.0 2.5 1.5 0.4

Service housinga 4.0d 4.6f 2.3 2.2 1.3 0.9

Service housing with 24-h assistance

1.7 3.4 5.6 7.1

Regular home care 19.2e 13.4 11.8g 11.2 11.8 11.8

Informal care allowanceb 3.3 2.7 3.0 3.7 4.2 4.7

Totalc 37.7 30.6 27.1 27.3 27.6 26.6

Sources: STAKES (1995), STAKES (2000), National Institute for Health and Welfare (2018a) (SOTKAnet data base) a Service housing means a specific housing model for older persons where each person has a small apartment of her/his own and where care services are available. Starting from year 2000, the social care statistics distinguish between ‘intensive service housing’ where care services are available 24 h and ‘ordinary service housing’ where assistance is not available around the clock b Informal care allowance includes a welfare benefit that is paid to some family carers, accompanied sometimes but not always by different kinds of support services (like respite care, home care, meals on wheels, etc.). For most services, the figures are based on the situation in one single day of the year. However, concerning informal care allowance, the reported figures represent the total number of users during the whole year c As the figures for informal care allowance as well as the service housing figures for 1990 and 1995 are registered in a different way from other figures, the total figures are only approximate d For most services, the figures are based on the situation in one single day of the year. However, concerning service housing for years 1990 and 1995, the reported figures represent the total number of users during the whole year e The term of ‘regular home care’ was adopted in social care statistics only in 1995. It means home care use that is provided either weekly or according to a specific care plan, which means that the user is not an occasional one. As the term was not yet used in 1990, the figure of regular home care use for that year has been estimated based on the total number of home care users (including ‘irregular users’) in 1990 and 1995 and the share of regular users (61%) out of the total number of users in 1995 f For most services, the figures are based on the situation in one single day of the year. However, concerning service housing for years 1990 and 1995, the reported figures represent the total number of users during the whole year g Until 2007, data on regular home care use was collected only on odd years. Therefore, the figure presented above for 2000 is actually from 2001

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

95

Care homes and nursing homes have become almost fully replaced by ‘service housing’, which was introduced in Finland in the 1980s. In this new service form, each user usually has a room of her/his own, called ‘apartment’, in the housing unit and pays rent for it. There are care services available in the unit, either during daytime (in ‘ordinary service housing’) or 24 h (in ‘service housing with 24-h assistance’), which are paid for separately. Statistics started to distinguish these two forms of service housing from each other only in 2000. In 1990, 4% of people over 75 used service housing, while in 2015 8% used it. ‘Ordinary service housing’ was rather popular at first but more recently it has become rare as ‘service housing with 24-h assistance’ has become the mainstream. Service housing has clearly become a sort of residential care, filling the gap left by shrinking provisions of traditional institutional care. However, this gap is filled only partly: while in 1990 altogether 15% of the 75+ population were using either traditional care institutions or service housing, in 2015 the figure was 10%. A third of the coverage rate of residential care has thus disappeared. The remaining gap was not covered by home care, either. The development has rather been the opposite. Though official policy in Finland has highlighted strongly the role of home care since the 1980s, the beginning of the 1990s saw a major drop in the coverage of home care for older people (Kröger & Leinonen, 2012). Home care became targeted more strictly to those with highest needs, in order to balance the decrease in the coverage of institutional care. A new concept of ‘regular home care’ was launched accordingly, introduced in the long-term care statistics in 1995. As a result of this development, many older people became excluded from publicly funded home care. In 1995, 61% of all home care users received ‘regular home care’ and if this information is used to estimate the use of ‘regular home care’ in 1990, it can be estimated to have covered 19% of the 75+ age group. By 2000, this had dropped to 12% and ever since, home care coverage has remained on the same level. If we count the provision of residential and ‘regular home care’ together, the coverage of long-term care has dropped from 34% of the 75+ population in 1990 to 22% in 2015. Even if we count in the growth of support to family carers of older persons from 3.3% in 1990 to 4.7% in 2015, the total coverage in 2015 proves to be 11% points lower than 25 years earlier. The drop took place during the recession of the 1990s but the coverage rate never recovered from that period. In long-term care, the whole period since 1990 could thus be described as a long era of austerity and cuts.

6.3  Decentralisation The era of cuts was initiated by a reform that was planned already during the late 1980s’ period of economic growth. Since 1984, municipal long-term care for older people had finally received similar central grants that health care, childcare and schools had been drawing since the 1970s (Kröger, 2011a). A significant part of the expenditures of rapidly growing municipal services was covered by central grants,

96

T. Kröger

which started to raise concern in the late 1980s. Central authorities and policy-­ makers questioned the grant system, claiming that it leads to ‘automatic expenditure growth’. As municipalities could count on central funding, they were not concerned about the raising costs of their service provisions, was the argument. Decentralisation of economic responsibility, through a reform of the central grant system, was chosen as the policy to turn the development. In the new system, local authorities would not receive central funding based on their expenditures but based on their geographic, demographic, and social characteristics. The reform did not just change the principle how central grants were determined but it also terminated almost all central regulation concerning municipal service provisions. Local authorities were given free discretion how to use the grants that they received. The idea was to discourage municipalities from extending their provisions and instead encourage them to cut their services and thus to save both local and central resources (Kröger, 1997; Niiranen, 1992). This new policy seemed to bring immediate results as the growth of municipal services came to a sudden halt and the development soon turned into an opposite direction. However, this outcome is largely explained by a surprising coincidence. The reform was drafted during a period of economic growth but in the early 1990s, Finland experienced a sudden and deep recession. This quickly led to major cuts in all public expenditures, including central grants to municipalities (Kröger, 2011a; STAKES, 2000). The grant reform was implemented in 1993 at a time when the recession was at its deepest in Finland. Local authorities were suddenly under huge financial pressures and they used their new freedoms to cut down many welfare provisions, long-term care being hit especially hard (Heikkilä & Rintala, 2006). The fear of policy-makers of increasing costs of growth of service provisions, in particular due to ageing, had led to a decentralisation reform that together with the recession halted the development and led to a long-standing stagnation in long-term care (Kröger, 1997).

6.4  Recentralisation The central grant system launched in 1993 is still in use in Finland but since the early 2000s it has drawn increasing criticism. The reform of 1993 gave local authorities the permission to freely formulate their own provisions and, not surprisingly, this led to growing variations in service provisions between different municipalities (STAKES, 2000). Around the turn of the century, these local variations attracted the attention of the media, which presented these variations as a source of regional inequality (Kröger, 2011a). As the whole Nordic welfare model is based on the principles of equality and universalism, such claims caused growing concern among the population and policy-makers (Heikkilä & Rintala, 2006). The 2000s and 2010s have seen several Finnish governments trying to make a major reform of the structures of social and health care. Tackling regional inequality has been one of the key starting points of these reform pursuits. At first, the

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

97

g­ overnment tried to reform the structure of local authorities, to create ‘stronger’ municipalities but this failed due to political disagreements between coalition parties of the government and also due to incompatibility of the reform plans with the Constitution of Finland (Kröger, 2011a). The current (2018) government has even raised the stakes and has been pushing for the reform using a novel approach: the government wants to create a new administrative level of regions and move the responsibility for social and health care from local authorities to these new regional authorities. Even this plan has attracted a huge amount of criticism, especially as it comes together with a plan to marketise a main part of social and health care provisions through the introduction of a wide-ranging customer choice model. A key motivation of the current government for the reform is, once again, concern for the anticipated growth of social and health care expenditures, due to population ageing. The government hopes to decrease the expected growth of care expenditures by three billion euro through the reform (Kröger, 2017). Critiques have claimed, though, that the reform will probably increase, not decrease expenditures. Also the need for savings has been questioned. Among others, the National Audit Office of Finland (2017) has stated that these saving plans are unrealistic and that actually there is no need for them as, in a European perspective, Finnish social and health care provisions are already efficient and ageing of the population is no more dramatic in Finland than it is in other countries. Whether the social and health care reform will be legislated by the Parliament of Finland is not clear at the moment. The bills are currently debated in parliamentary deliberations. The government holds a majority in the Parliament but only narrowly and the reform plans have been subject to massive criticisms. One thing is clear, however. The decentralisation reform of 1993 was largely motivated by ‘demographic panic’ and the same goes to the reform plans of the 2010s. However, this time the planned policy instrument is the opposite: the government plans to recentralise social and health care, to take them away from local authorities and to put them in the hands of new regions that are to be centrally regulated to a much higher degree than the municipalities have been ever since 1993. The regions are expected to do what the municipalities are now claimed to have failed to do: to prevent the anticipated growth of care expenditures, due to population ageing, by cutting further the provisions of social and health care to older people.

6.5  Deinstitutionalisation Long-term care statistics presented above show that since the early 1990s, institutional provisions have experienced a dramatic and continuous decrease in Finland. Still in the early 1980s, care homes organised by local social welfare agencies and long-term wards in local hospitals were the two mainstream solutions for intensive long-term care needs. In international comparison, these services covered a rather high share of older people. Also in this respect, things started to change in the late 1980s. Criticism of all kinds of institutions had been going on since the 1960s and

98

T. Kröger

in the 1980s this criticism reached long-term care institutions, which were claimed to provide inhuman and non-individual care that did not respect human dignity of older people. Ageing in place was soon adopted in Finland, like in many other countries, as a new frame of reference in long-term care (Kröger et al., 2003; Kröger & Bagnato, 2017). ‘Service housing’ was introduced as a new kind of care service, being claimed to provide more individual care than what was offered by traditional institutions. Most service housing units offered one-person rooms, which brought more privacy compared to traditional institutions that often had several beds in each room. The original idea of service housing was that people could move there rather early and gradually use more services when their needs increase (Kröger et al., 2003). This objective was lost, however, as soon service housing units started to remind traditional residential units. Their users had more and more needs and as services had to be provided in a more intensive way than originally planned, a new term of ‘intensive service housing’ (aka ‘service housing with 24-h assistance’) was taken into use and distinguished from ‘ordinary service housing’. Since then, ‘ordinary’ units have disappeared and ‘intensive’ units have become units of rather traditional residential care. Cutting down institutional care has not been motivated in Finland only by a strive to get rid of inhuman practices and to enhance the quality of care. From early on, policy documents have highlighted that institutional care is expensive and should therefore be avoided. Central authorities have given local authorities guidelines that have stipulated maximum levels of institutional provision that municipalities should not exceed. Soon ‘intensive service housing’ started to be counted in as residential care in these recommendations. Coverage levels are expected to decrease over time: the clear and outspoken policy objective has been to reduce the coverage of residential provisions. The motivation for these recommendations has been primarily to cut the costs of long-term care services, not to enhance the quality of services (Kröger, 2011a; Kröger et al., 2003). The staff:user ratio in Finnish residential care is lacking much behind the other Nordic countries and the conditions of home care have also considerably weakened since 2005 (Kröger, Van Aerschot, & Mathew Puthenparambil, 2018). This would not be the situation if serious attention would have been addressed to quality issues. The adoption of the ageing-in-place framework has been used as a ground for continuous efforts to decrease institutional care provisions but in Finland the deinstitutionalisation policy did not bring any further investment in home care. As a result, home care has failed to take over the responsibility for older people with high service needs (Kröger & Leinonen, 2012). As many older persons do not receive adequate care at home, the result has been growing waiting lists to institutional care. This negative development is explained by that deinstitutionalisation has been used in Finland primarily as a cost-cutting instrument within the context of growing numbers of people in old age, not as a method of responding to growing care needs with home-based services that promote increased quality of life for older people.

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

99

6.6  Refamilisation A key function of formal care provisions is their contribution to defamilisation, that is, taking over a part of care responsibilities of families and thereby reducing family dependencies. Defamilisation strengthens the autonomy and rights of individuals and also makes the access to care more equal between people with dissimilar levels of family resources (Kröger, 2011b; Saraceno, 2010). From the perspective of defamilisation, Nordic welfare states have regularly been described as the leading welfare regime. The emergence and growth of publicly funded formal care services has given people other options besides family care. However, since the early 1990s the development of long-term care in Finland has been characterised by refamilisation, not defamilisation, as the responsibilities of families for the care of their older members have been increasing, not decreasing. Concerning the character of familisation, Chiara Saraceno (2010, 2016) has made a distinction between familialism by default, where the welfare state does not provide support or alternatives to family care but expects it to take the responsibility for care, and supported familialism, where families are supported to keep up their financial and caring responsibilities through financial transfers and other welfare policies. According to Saraceno (2016, 316) familialism by default clearly upholds gender and social class inequality, as it leaves the responsibility to provide and finance care to the family, while the effects of supported familialism are more ambivalent. Finnish policies have sometimes been highlighted as a textbook example of supported familialism as since the 1980s there has been a payment-for-care that many local authorities have paid to family carers and as this is paid directly to the carer (and not to the older person) and as also respite care has been developed in Finland since the 1990s (e.g. Saraceno, 2010, 37). The care statistics presented above show that, besides service housing that has been replacing traditional institutional care, the only long-term care provision that has grown since the early 1990s in Finland is support for family carers. While institutional and home care provisions have become targeted considerably more strictly than earlier, the coverage of informal care support has grown continuously. The motivation behind this policy has not been only to recognise the value of the work of family carers but also to encourage them to stay in their caring role and, thus, to reduce the demand for publicly funded care services (Kröger & Leinonen, 2012). Supported familialism has been used by the Finnish authorities as a strategy to prevent pressure towards an increase of care provisions and towards growing care expenditures (See Sipilä & Simon, 1993). However, supported familialism is only a part of the whole development that has taken place in Finland. As we could see from Table 6.2, the growth of support for informal care has not compensated the cuts in the coverage rates of formal care services. The gap that emerged in the 1990s has never become filled, which means that a considerably larger part of older people need currently to depend on themselves and their families than what was the situation 30 years ago. Only one out of four persons aged 75 or over received some kind of publicly funded long-term care

100

T. Kröger

in 2015, though many more are in need of support in their everyday lives. This means that familialism by default has also landed in Finland. Care responsibilities are being pushed back to many families, though attitude surveys show that older people and their family members expect the state to provide the necessary care to people in old age. Unwilling provision of family care seems to have increased. This development was strengthened by a change in municipal home care practices: earlier services covered personal care as well as household tasks but since the 1990s, household tasks have become almost fully excluded from municipal provisions. Families have had to step in and take more responsibility for cleaning, meals and other tasks that are not anymore part of more and more medically oriented home care. At the same time, many older people do not receive formal personal care, either, so families are expected to increase their responsibilities not only for household tasks but also for personal care. And finally, service fees for formal care have become raised and their structure has become altered—so that, for example, in service housing the basic monthly fee does not yet include care services—which has increased the financial burden of older people and their families (Karsio & Anttonen, 2013). All in all, after a period of defamilisation during the building up of public care services in the 1960s, 1970s and 1980s, Finland has experienced an era of refamilisation since the early 1990s, displayed in decreasing coverage levels of formal care provisions. The main motive for this change of direction was the need to cut public expenditures due to the major recession of the early 1990s. That recession passed by in a few years, but the policy of refamilisation has remained. It has been practised in Finland since the 1990s as a precaution for the feared demographic time bomb, as an instrument to curb the anticipated growth of public care expenditures.

6.7  Marketisation The decentralisation reform of 1993 did not only change the way how central grants are allocated but it also freed local authorities from almost all central regulation, also concerning outsourcing. Until then, municipalities had been allowed to outsource their service provisions to non-public providers only to a very limited extent but now this limitation was abolished. By 1993, practically no for-profit long-term care provision existed in Finland. Non-profit organisations had played a minor part in provision of care services for older people—and in the innovation and experimentation of new models (like home care in the 1950s) they had been major players, collaborating closely with public social and health care authorities (Kröger, 2002). Local authorities had delegated certain parts of care provisions, like the new sector of service housing, to non-profit providers. Since the mid-1990s, based on EU regulations, close connections between non-profits and local authorities started however to be seen as inappropriate, distorting the competition in the market, and new for-­ profit providers started to emerge rapidly.

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

101

Since the 1990s, encouraged by the EU, Finnish municipalities have increasingly used competitive tendering to outsource a major part of their care service provisions. In these tenders, non-profits need to compete with for-profits on equal terms and, though non-profit providers have kept their share of service provisions, it is for-profit provision that has been growing rapidly. In 1990, only 0.5% of all social service personnel in Finland were working for for-profit organisations while in 2014 the figure was already 18.6%. In care for older people, the share of for-profits is even higher than in all social care: 21.3% of eldercare staff were employed by for-­profit providers in 2014 (Karsio & Anttonen, 2013, 107; National Institute for Health and Welfare, 2018b). Outsourcing of municipal care provisions has not been the only way that Finnish authorities have promoted the growth of for-profit care provisions. In 2001, a new tax rebate scheme was introduced. People, who use their own money to purchase for-profit home care (or home renovation) services, started to receive half of the service fees back through a new rebate included in the income tax system. As people with low incomes (like older people receiving only the flat rate national pension) do not pay much income taxes, this scheme was drafted specifically for the middle and upper classes. Around the same time, service fees for publicly funded long-term care were raised especially for people with good incomes. These changes were implemented clearly to attract these groups to use for-profit care services instead of public provisions. Furthermore, middle and upper classes were averted away from the public care system by the tightening access to public care. Put together, these marketisation policies would fill their expected function in lessening the demand for public care but, on the other hand, they also set in motion the development of a two-tier service system in Finland. Low-income groups continued using public care services, having no choice, while other groups would move gradually and increasingly to use for-profit provisions. Pushing people to use marketised care and to pay an increasing share of the costs may have been a functioning strategy to decrease the threat of expanding costs of public long-term care. However, this policy has also eroded universalism, the basic principle of the Nordic welfare model, and led to the emergence of a two-tier system where older people with low income use publicly provided long-term care services and increasingly family care, while those who can afford it, purchase for-profit services to fill the gaps left by cuts and retargeting of public care (Mathew Puthenparambil, Kröger, & Van Aerschot, 2017).

6.8  Conclusions Since the early 1990s, long-term care in Finland has experienced many changes. Governance of the care system has been reformed first using decentralisation and now recentralisation, both in order to curb the growth of expenditures of care provisions of local authorities. Traditional institutions have become replaced by service housing and overall the coverage of residential provisions has considerably

102

T. Kröger

decreased. The gap left by reduced institutional care has not become covered by a corresponding investment in home care. On the contrary, the coverage of home care also dropped radically in the 1990s and has never recovered since. The main goal of Finnish long-term care policy has ever since been to minimise institutional care and to keep older people at home as long as possible. Access to both institutional and home care has been made more difficult and older people are increasingly pushed to look for support from their families and from the emerging market of for-profit care services. The overarching motivation for all these policy changes has been the wish of policy-makers to avoid responsibility. None of these reforms has been made in order to face the actual needs of the ageing population and to provide the support that is needed. Instead, these policies have been implemented specifically in order not to provide the necessary assistance and care. Demographic panic has been the foundation of long-term care policy-making in Finland since the late 1980s and the authorities have focused their attention and innovativeness to find ways how the public sector can escape from facing the real needs of ageing citizens and their family members. In performing this task, the authorities have not lacked ideas and efforts. First, in 1993, they implemented decentralisation in the fear of the demographic time bomb and now, 25 years later, they for the same reason wish to implement recentralisation. Deinstitutionalisation, refamilisation and marketisation have all been used primarily in order to cut down public responsibilities for long-term care. The primary goal of all these reforms has been to curb the anticipated growth of expenditures of care provisions. No real effort has been made to meet long-term care needs better than earlier as the attention of policy-makers has been in looking for the easy way out. However, there is no easy way out because ageing of the population and the related growth of care needs is a simple fact. The Finnish welfare state has so far refused to recognise this fact and tried to avoid responsibility for increasing long-term care needs. However, burying one’s head in the sand is not a very effective public policy in the advent of a looming care crisis.

References Anttonen, A. (1990). The feminization of the Scandinavian welfare state. In L.  Simonen (Ed.), Finnish debates on Women’s studies (pp. 3–25). Tampere: University of Tampere. Anttonen, A. (2002). Universalism and social policy: A Nordic-feminist revaluation. NORA  Nordic Journal of Feminist and Gender Research, 10(2), 71–80. Anttonen, A., & Karsio, O. (2017). How marketisation is changing the Nordic model of care for older people. In F. Martinelli, A. Anttonen, & M. Mätzke (Eds.), Social services disrupted: Changes, challenges and policy implications for Europe in times of austerity (pp. 219–238). Cheltenham: Edward Elgar. Heikkilä, M., & Rintala, T. (2006). Rescaling social welfare policies in Finland. Vienna: European Centre for Social Welfare Policy and Research. Karsio, O., & Anttonen, A. (2013). Marketisation of eldercare in Finland: Legal frames, outsourcing practices and the rapid growth of for-profit services. In G. Meagher & M. Szebehely (Eds.), Marketisation in Nordic eldercare (pp. 85–125). Stockholm: Stockholm University.

6  Looking for the Easy Way Out: Demographic Panic and the Twists and Turns…

103

Kröger, T. (1997). Hyvinvointikunnan aika. Kunta hyvinvointivaltion sosiaalipalvelujen rakentajana [The time of the welfare municipality. Local authorities as constructors of social services]. Tampere: Tampereen yliopisto. Kröger, T. (2002). Paikallisuus, monituottajamalli ja politiikka—Miksi ikääntyneiden palvelut tuotetaan eri paikkakunnilla eri tavoin? [Localness, welfare mix and politics: Why are services for older people produced differently in different localities?]. In J. Lehto & K. Natunen (Eds.), Vastaamme vanhusten hyvinvoinnista. Sosiaali- ja terveyspalvelujärjestelmän sopeuttaminen vanhusten tarpeisiin (pp. 82–95). Helsinki: Kuntaliitto. Kröger, T. (2011a). Retuning the Nordic welfare municipality: Central regulation of social care under change in Finland. International Journal of Sociology and Social Policy, 31(3/4), 148–159. Kröger, T. (2011b). Defamilisation, dedomestication and care policy: Comparing childcare service provisions of welfare states. International Journal of Sociology and Social Policy, 31(7/8), 424–440. Kröger, T. (2017). Sosiaali- ja terveyspalvelujen reformaatio [Reformation of social and health care]. Janus: Sosiaalipolitiikan ja sosiaalityön tutkimuksen aikakauslehti, 25(2), 160–165. Kröger, T., Anttonen, A., & Sipilä, J. (2003). Social care in Finland: Weak and strong universalism. In A. Anttonen, J. Baldock, & J. Sipilä (Eds.), The young, the old and the state: Social Care Systems in Five Industrial Nations (pp. 25–54). Cheltenham: Edward Elgar. Kröger, T., & Bagnato, A. (2017). Care for older people in early twenty-first century Europe: Dimensions and directions of change. In F.  Martinelli, A.  Anttonen, & M.  Mätzke (Eds.), Social services disrupted: Changes, challenges and policy implications for Europe in times of austerity (pp. 201–218). Cheltenham: Edward Elgar. Kröger, T., & Leinonen, A. (2012). Transformation by stealth: The retargeting of home care services in Finland. Health and Social Care in the Community, 20(3), 319–327. Kröger, T., Van Aerschot, L., & Mathew Puthenparambil, J.  (2018). Hoivatyö muutoksessa. Suomalainen vanhustyö pohjoismaisessa vertailussa [Care work under change: Finnish care work for older people in Nordic comparison]. Jyväskylä: Jyväskylän yliopisto. Mathew Puthenparambil, J., & Kröger, T. (2016). Using private social care services in Finland: Free or forced choices for older people? Journal of Social Services Research, 42(2), 167–179. Mathew Puthenparambil, J., Kröger, T., & Van Aerschot, L. (2017). Users of care services in a Nordic welfare state under marketisation: The rich, the poor and the sick. Health and Social Care in the Community, 25(1), 54–64. Mullan, P. (2000). The imaginary time bomb: Why an ageing population is not a social problem. London: I.B. Tauris and Co. National Audit Office of Finland. (2017). Fiscal policy evaluation assessment on the management of general government finances 3 November 2017. Retrieved April 15, 2018, from https://www. vtv.fi/files/5919/Fiscal_policy_evaluation_assessment_on_the_management_of_general_government_finances.pdf. National Institute for Health and Welfare. (2018a). SOTKAnet statistical data base on welfare and health in Finland. Retrieved April 15, 2018 from sotkanet.fi. National Institute for Health and Welfare. (2018b). Terveys- ja sosiaalipalvelujen henkilöstö 2014 [Health and social care staff in 2014]. Retrieved April 15, 2018, from http://www.julkari.fi/ bitstream/handle/10024/135915/TR_01_18.pdf?sequence=1. Niiranen, V. (1992). Vapaakuntakokeilun käyttöarvo sosiaalitoimessa [The applicability of the free municipality experiment in social services]. Helsinki: Valtion painatuskeskus. Rauhala, P.-L. (1996). Miten sosiaalipalvelut ovat tulleet osaksi suomalaista sosiaaliturvaa? [How did social services become a part of social security in Finland?]. Tampere: Tampereen yliopisto. Saraceno, C. (2010). Social inequalities in facing old-age dependency: A bi-generational perspective. Journal of European Social Policy, 20(1), 32–44. Saraceno, C. (2016). Varieties of familialism: Comparing four southern European and east Asian welfare regimes. Journal of European Social Policy, 26(4), 314–326. Statistics Finland. (2018). StatFin data bank: Population structure, population projections. Retrieved April 15, 2018 from stat.fi.

104

T. Kröger

Sipilä, J., & Simon, B. (1993). Home care allowances for the frail elderly: For and against. The Journal of Sociology & Social Welfare, 20(3), 119–134. Sipilä, J. (Ed.). (1997). Social care services: The key to the Scandinavian welfare model. Aldershot: Avebury. STAKES. (1995). Sosiaali- ja terveydenhuollon palvelukatsaus. Helsinki: STAKES. STAKES. (2000). Sosiaali- ja terveydenhuollon palvelukatsaus 2000. Helsinki: STAKES. Statistics Finland. (2018). StatFin data bank stat.fi: Population structure, population projections. Accessed April 15, 2018. Szebehely, M. (2003). Hemhjälp i Norden  – Illustrationer och reflektioner [Home care in the Nordic countries – Illustrations and reflections]. Lund: Studentlitteratur. Szebehely, M., & Meagher, G. (2018). Nordic eldercare—Weak universalism becoming weaker? Journal of European Social Policy, 28(3), 294–308. Vincent, J. (1996). Who’s afraid of an ageing population? Nationalism, the free market, and the construction of old age as an issue. Critical Social Policy, 16(47), 3–26.

Chapter 7

Policy Responses to Aging: Care Services for the Elderly in Norway Rune Ervik

7.1  Introduction1 Norway and other OECD countries are experiencing demographic changes in terms of an increasing share of the elderly population. To illustrate these changes the old age dependency ratio (OADR)2 measuring the relative share of the dependent population (65+) to the active working age population (20–64) provides the following development for Norway: in 1950 the ratio was 17.3, in 2010 the ratio increased to 22.5 and in 2060 it is expected to grow to 43.0 (Eurostat, 2011). Moreover, with increasing longevity the period defined as ‘dependent’ is steadily increasing. This can be observed by looking at how life expectancy after pensionable age develops. In 1958 the life expectancy after pensionable age was 9.5  years for men and 11.1 years for women. In 2010 this increased to 15.7 for men and 18.9 years for women and in 2050, life expectancy after pensionable age is further expected to increase to 18.9 years for men and 22.5 years for women (OECD, 2011). Although these changes are substantial in the longer perspective, the aging challenge in Norway and the other Scandinavian countries are considered as moderate in a broader comparative perspective. Here countries including Japan, Korea, but also Italy and Poland face very large projected changes of their old age dependency ratios towards 2050 (OECD, 2006, Table  1.1, p.  20). China is also very fast aging, witnessed by the short time period it will take for the aging population (65+) to double from 7 to 14% of the total population. This happened in 26 years for Japan,  Many thanks are due to colleagues Tord Skogedal Lindén, Hilde Danielsen and other colleagues within the Uni Research Rokkan Centre research group on Health, Welfare and Migration for providing valuable comments and suggestions on a previous version of this paper. 2  OADR: (Age 65+/age 20–64)×100. This provides the ratio as a percentage. 1

R. Ervik (*) NORCE Norwegian Research Centre, Department for Social Sciences, Bergen, Norway e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_7

105

106

R. Ervik

but is expected to happen shorter for China, compared to 45 years for Germany and the UK, 85 years for Sweden and 115 years for France (Cook & Halsall, 2012). Aging policy broadly defined as policy measures to address the consequences of demographic aging practically covers all sectors of society and thus have clear parallels to environmental and climate policy in terms of its wide societal impact. Within the welfare state domain, policy developments have concentrated on three main areas: pension reforms, health and long term care, and labour market policy (UNECE United Nations Economic Commission for Europe, 2007). Here, the focus is on long term care (LTC), and to be more precise on LTC for the elderly population (i.e. elderly care services) defined as those aged 67 years or older. Long term care is defined as ‘the care for people needing support in many facets of living over a prolonged period of time’ (Colombo, Llena-Nozal, Mercier, & Tjadens, 2011). Care services includes a wide variety of tasks from assistance with practical tasks of daily life activity (cleaning, shopping and preparing meals, clothing, etc.) to nursing services (i.e. dosing medicine, treatment of wounds) and rehabilitation and training activities, as well as housing and residential care. What challenges do governments and key policy actors in Norway identify? What policy ideas and responses have been developed in the time period c. 2000– 2015? What could be relevant from these experiences when developing services for the elderly in other countries? The Scandinavian countries have all engaged in policy innovations in order to consolidate sustainable welfare states, including care solutions for a growing elderly population. First, the strategy of active aging has also made its imprints within elderly care through the concept of ‘active care’, representing new ways of defining the content and quality of care. Second, another important dimension concerns the ‘welfare mix’ referring to the relative role of the main institutions of society, family, state, market and the voluntary sector, in providing resources and delivering care (Estes & Zhou, 2015). A hallmark of the Scandinavian countries in this respect has been the relatively strong role of the public sector in financing and delivering care services. However, as part of an ongoing debate on future care services there are voices arguing for a changed welfare mix in care in which increasing responsibility is given to the three other institutions. A third dimension of innovations concerns the use of ‘welfare technology’ to enable elderly people (and other age groups in need of care services) to live more independent lives and to assist care workers in their work tasks.3 The chapter is structured as follows: In the first part a description of the current situation, in terms of user shares of the elderly population, employment within the sector and its financing is provided. The next part will briefly provide an account of how the welfare mix within long term care for the elderly has developed historically. In the third main section, the three dimensions of policy ideas, innovations and responses are analysed, whereas section four sums up and concludes.  Broadly ‘welfare technology’, that mostly is a term applied in the Scandinavian countries, is technology applied to improve and make more efficient, welfare services provided by the welfare society to their citizens (Nordens Välfärdscenter, 2010, p. 7). An example is GPS tracking used in dementia care to increase the freedom of users with dementia to move around in the local community without restrictions. Moreover, the tracking device enables carers to find and assist users who have got lost and are unable to find their way home. 3

7  Policy Responses to Aging: Care Services for the Elderly in Norway

107

7.2  E  lderly Care Services in Norway in Comparative Perspective Care service users included 271,406 users, of these 168,354 users were aged 67 years or older at the end of year 2013 (Mørk, Sundby, Otnes, & Wahlgren, 2014). In relative terms, these elderly care users make up 24% of the population above 67 years.4 Of these 33,968 received care in institutions, nursing homes, 31,970 of these aged 67 years and older (4.6% of the 67+ population). Additionally, 16,873 received care in sheltered housing, 7909 of these were in the 67+ group (1.1%). Whereas the above figures give the stock of care users at the end of the year, a different counting reveals an even more extensive picture of the importance of care services, including all those that have received some form of services throughout the year. For 2013 this amounted to a total of 345,254 users. As a percentage of the total population this makes up 6.6% and it remains at this level also for 2015 (Mørk, Beyrer, & Haugstveit, 2016). Employment in public care services is substantial and is also a key sector for female employment. Over 80% of employees within the health and care sector are women. In 2011, 128,900 work years were performed within the care service sector (Holmøy, Kjelvik, & Strøm, 2014) (e.g. 5.6% of total number of work years this year). The total number of work years performed within the overall health and care sector was 264,900 and this amounts to 11.5% of the total number of work years performed for 2011 (op.cit). In terms of financing Norway has a tax based, universal public long term care scheme. All LTC services are delivered in kind at the local municipal level and are financed by national taxes. Total LTC costs for the municipalities in 2012 were NOK 90 billion (94.13 billion CNY), c. 14.9% of total public social expenditures5 and6 Of these, just over 7% was covered by private sources as co-payments (Meld. St. 29, 2012–2013). Municipalities are free to set co-payments for residential care (sykehjem) and home care (hjemmetjenester), within legal boundaries. For nursing home care (hjemmesykepleie), and services for personal and own care, no co-­ payments are allowed. For home care there are income-related co-payments on a progressive basis. For long term residential care, patients must pay 75% of their income above NOK 7500 (7330 CNY) and up to the basic amount (Grunnbeløpet) of NOK 88,370 (86,366 CNY) in 2014, plus 85% of any excess income up to the full cost of a nursing home place for the municipality in question (Colombo et al., 2011; Norwegian Ministry of Health and Care Services, 2014).7 In contrast, for instance to the UK, property and capital assets are left untouched.  This calculation is based on the population of 5,258,000 as of first January 2014 (Statistisk sentralbyrå, 2014a). 5  Amounts in Chinese Yuan (CNY) reflect currency exchange rates for the respective year (Norges Bank, 2015). 6  Total public social expenditures for 2014 made up 22.0% of GDP (OECD, 2015). 7  The basic amount is a central factor in determining the pension benefits of the public National Insurance system (Folketrygden). It is adjusted yearly as from the first of May. Median income for a one person household aged above 65 was NOK 238,500 (249,450 CNY) for 2013 (Statistisk sentralbyrå, 2014c). 4

108

R. Ervik

Although the public sector provides the largest share of care services in terms of employment and man-years effort, this does not mean that family care is absent. In fact, the most recent assessment of the scope of unpaid family care performed amounts to around 100,000 working years (Holmøy et al., 2014). In order to point out how the Norwegian care model/regime differs from other countries in the European context, typifying various care regimes, the following overview provides some traces focusing on financing, divisions of institutional responsibility, service intensity and composition of the welfare mix in delivery of services.8 It should be noted that comparing LTC schemes is inherently complex. Comparative data are hard to find and interaction between health care and LTC blurs their boundaries and raises issues of functional equivalence (Ervik, Helgøy, & Lindén, 2013, p. 235). The table reveals that the Norwegian care regime spends more and relies more strongly on public financing and provision than the UK regime. Provision in Norway takes place through formal employment of care workers, and so reveals a stronger degree of defamilization than the care regime of Germany (and the UK).9 Moreover, quality measured as users per LTC worker indicates higher care intensity in Norway compared to the two other countries. Including Denmark and Sweden into this overview would place them closest to the Norwegian case. The key characteristic of the universal care model of the Nordic countries is comprehensive, publicly financed and high quality services available to all citizens according to their needs rather than their ability to pay (Erlandsson, Storm, Stranz, Szebehely, & Trydegård, 2013, p. 24). Importantly, service universalism also implies that they are attractive to all potential beneficiaries: ‘services should be affordable to those with fewer resources and flexible enough to respond adequately to the needs and preferences of a heterogeneous population- both the demanding middle class and those less well of, as well as members of cultural minorities’ (Vabø & Szebehely, 2012, p. 121).

7.3  T  he Evolving Welfare Mix in Historical Perspective: From Family to Public Community Care In Norway as elsewhere, the close family and relatives for centuries had a judicial responsibility for older people and other groups in need of help and care.10 Moreover, the old people’s home, the predecessor of today’s nursing homes and care service housing, was previously a part of the municipalities and their poverty policy including the care of poor people (fattigpleien) (Romøren, 2011). In developing these services into a particular elderly care service area, also to be differentiated into a  This section draws on previous research on LTC, cf. Ervik et al. (2013).  According to Bambra (2007, p. 327) defamilization: ‘refers to the extent to which the welfare state enables women to survive as independent workers and decreases the economic importance of the family in women’s lives’. 10  The 1964 Act on Social Care ended the judicial duty for children to provide maintenance and care to their parents (Romøren, 2011, p. 206). 8 9

7  Policy Responses to Aging: Care Services for the Elderly in Norway

109

distinct policy field, voluntary non-profit organizations were crucial in the post-war years and continued work that they had started in the interwar period (Seip, 1994, pp. 284–285). Organizations such as Norwegian Women’s Public Health Association (Norske Kvinners Sanitetesforening) and The National Association for Public Health (Nasjonalforeningen for Folkehelsen) were particularly active in working for the elderly and they aimed at a closer cooperation with the public sector, both municipalities and the state. Together the two organizations in 1950 initiated the establishment of the old people’s health committee (De gamles helsekomite) that was to serve as a forum for cooperation between these organizations and between them and the public sector. By establishing the Norwegian Gerontological Society (Norsk Gerontologisk Selskap) in 1954 and the Gerontological Institute in 1957, elderly care was defined as a national problem responsibility and as an object for research to provide knowledge for a modern public care policy. Seip (1994) identifies the combination of economic problems and crisis in the private voluntary organizations work, as gifts were declining and costs, for instance wage costs, were increasing. One reason given for the decline in gifts according to the organizations was that people steadily were increasing their contributions to the public sector via tax payments, etc. The share volume of care needs for elderly also was on the increase. Moreover, because there was a close link between people working in the organizations and the public institutions the gradual transformation towards a stronger public involvement was made more smoothly. At the local level the municipalities extended their engagement for the care of elderly by building residential care institutions. In 1940, 476 such institutions were registered with around 13,600 residents. These residents made up 6.2% of the population above 67 years in 1940. In 1960 there was 754 institutions with 22,400 residents (6.6% of those 67 years or older).11 Around 70% of these institutions were owned by the municipalities (op.cit, p. 286). This public provision of care for the elderly expanded in the 1960s in Norway (Næss, 2008, p. 233). There was a tremendous growth of this sector from the mid 1960s, and during the 1970s and the 1980s, no other sector had a larger employment expansion. Thus, in 1965, there were 597 nurses in home care and 3978 home carers employed in Norway. Ten years later this figure had grown to 2249 nurses and 31,490 home carers (Statistisk Sentralbyrå, 1978: Table  333, p.  598). Home nursing care increased the number of full time labour years by 257% from 1970 to 1980, and home care increased 203% during the same decade (St.meld.nr. 25, 2005–2006, p.  22). Historically and today, most care work has been and is performed by women. The transformation of elderly care from family to community, with public services as the core, opened up an important avenue for wage work for women. An important driver of this change was also the women’s movement struggle for breaking with traditional gender roles and strengthening their economic independence (Danielsen, 2015). With the build-up of child care institutions, this eased the combination of wage work and family tasks, and spurred substantially higher labour market participation rates for 11

 Information on historical population statistics gathered from Statistisk sentralbyrå (2015).

110

R. Ervik

women in all the Scandinavian countries compared to other European regions and welfare models. However, as noted previously, the growth in female employment has been concentrated within the care sector and has led to a highly gender divided labour market. In public debates on how this restricts women’s career and employment opportunities, this is referred to as the gender equality paradox (cf. Reisel & Teigen, 2014). Moreover, the substantial extent of part-time work for women, especially within the care sectors, also represents a potential problem as it may jeopardize their economic independence (Le Feuvre, Ervik, Krajewska, & Metso, 2012). In sum, the post-war period up to the 1990s witnessed a changing mix of financing and provision of elderly care from the family and voluntary organizations towards increasing public financing and provision within the ‘welfare municipality’ (velferdskommunen) (Nagel, 1991). In the institutional mix for this period, the for-­ profit market sector has been marginal.

7.4  Challenges, Ideas and Policy Responses Recent green and white papers on care stress the need to innovate and bring out new solutions to the future care challenges in light of an aging society (Meld. St. 29, 2012–2013; NOU, 2011, p. 11). The green paper on Innovation in care (Innovasjon i omsorg) identifies six major challenges: These are new user groups with a strong growth of younger users with disabilities. The second concerns aging and growth of care needs with a focus on dementia. A third challenge is a future of scarcity of care providers: changing demographics will lead to a relatively decreasing labour force. A stable family care provision implies the public sector must meet the whole increase in demand in a locally based care service where a closer cooperation between family, volunteers and local community is needed. As part of the scarcity of labour challenge, there is also an increasingly important international aspect in terms of a growing import and export of care workers between countries, as well as a market of larger international companies providing care services, identified as a fourth challenge. A need for better medical treatment of users of LTC services represents a fifth problem area. Finally, there are existing weaknesses of the quality of care in terms of lacking activities in daily life associated with social and cultural needs and the concept of care is in danger of encompassing a too passive and dependent role for the care receiver (NOU, 2011, pp. 11, 22–23, 42). In the following three sections the aim is not to cover all of these problem areas, the ambition is instead to provide some brief accounts, relating to the above challenges, concentrating especially on the issue of active care, aging and the future scarcity of care workers and what ideas and policy responses are contemplated in public debate.

7  Policy Responses to Aging: Care Services for the Elderly in Norway

111

7.5  N  ew Policy Ideas on Aging and Care: Active Aging and Active Care Part of the innovative aspect of the care policy debate is to provide new ideas on how we are to relate to aging and future elderly care. Here the committee on innovation in care identifies a need to develop what they denote as an active senior policy, which involves all sectors of society, not only those confined to pensions and the labour market. This active senior policy is presented with reference to the concept of active aging. The World Health Organization defines active aging as ‘the process of optimising opportunities for health, participation and security in order to enhance quality of life as people age’ (World Health Organization, 2002). This definition stresses that active refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labour force. It is based on the human rights of older people, as encompassed in the UN principles of independence, participation, dignity, care and self-fulfilment. In this way it represents an approach that recognizes the rights of people to equality of opportunity in all aspects of life, as they grow older (Op.cit p. 13). Although there is no universally agreed upon definition of ‘active aging’ according to Walker and Foster (2013), of central importance for the care area is that active aging encompasses all elderly people, also those who are vulnerable and dependent, that it is a preventative concept involving the whole life course, and that it entails a strategy for participation and empowerment. This translates into a practical policy that ought to emphasize new working methods and approaches in terms of active care, daily life rehabilitation, culture and well-being. Two examples may briefly illustrate some of the new content of this policy: First, under the heading of ‘active care’ a program called ‘the cultural walking stick’ (Den kulturelle spaserstokken) aims to stimulate cross-sectoral cooperation between the cultural sector and the health and care services within the municipalities (St.meld nr. 25, 2005–2006, pp. 101–102). An important background for this initiative was research pointing to the lack of social and cultural activities within the municipal care sector; especially this concerns inhabitants of residential care institutions, and other groups with a substantial need of assistance. The policy offers arrangements and activities within all kinds of arts and culture as music, theatre, film, literature and paintings. These arrangements are open for all and use already established arenas in the neighbourhood, such as culture and church houses, nursing homes and care centres. The program includes  cooperation with smaller and larger cultural institutions, with artists and performers, and local cultural life, both professionals and amateurs. An important goal of the initiative is to increase the activity across generations and ethnicity. Moreover, seeking to enable the least resourceful older people to participate in cultural activities also contributes towards an overarching goal of universal access to cultural activities. Being modelled on another initiative aimed at addressing cultural needs of young persons in school age, the extension of this to include older persons points to a life course based approach.

112

R. Ervik

The second example of ‘active care’ concerns the issue of daily life rehabilitation and a preventative approach stimulating activity and participation. The municipality of Voss is pioneering this method in a Norwegian context through the so-called ‘Vossamodellen’, which is strongly inspired from innovations initially made in the Danish municipality of Fredericia. The goal of the model is to delay the time for entrance into dependence on care services, to enhance the quality of life for the patients, increase care worker’s satisfaction with their work and liberate capacity of the care and health services for other important tasks (Hauglum, 2012). Daily life rehabilitation is short-term and intensive interdisciplinary rehabilitation. It consists of groups of occupational therapists, physiotherapist and home nursery care staff in cooperation with the user to exercise and adopt the home and local community in order to make the user more self-reliant and less dependent on help (Høyskolen i Bergen, 2015). The LTC services have changed from being mainly elderly care, to provide care for dependent groups of all ages (Gautun & Grødem, 2015). Younger groups of disabled people and their organizations have been important in changing the focus of services from ‘care’ and dependency to ‘independent living’ and ‘empowerment’ of user groups and individuals. Being critical of the traditional care concept as being passive and paternalist, they have fought for changes in these services to become more attentive to user control and to provide practical assistance. In this way, there are clear parallels between the active aging paradigm, the concept of active care and the values exposed by the independent living movement. In sum, the two examples briefly presented show how innovations in care concerning the organization of working methods and inclusion of new professional groups potentially can address challenges of passivity and loneliness, as well as problems caused by physical disabilities. Taken together these may also effect positively on cognitive abilities and delay their impairment. Politically, there is a strong consensus in Norway on the concept of active care and a change of policy towards emphasizing prevention and rehabilitation (Innst. 477 S, 2012–2013; St.forh, 2012– 2013). However, there is traditional political disagreement between Left and Right in how far public responsibility should reach. For instance, the incoming non-­ socialist government ended public financing support to the ‘cultural walking stick’ arrangement, prioritizing core health and social services instead. This brings us to the next issue addressing the question on how a new balance between institutional financing and providers of care may contribute in improving aging policy.

7.6  W  elfare Mix Changes in Care: Altered Institutional Roles in Financing and Provision? Because of concerns for the financing of future care needs, many governments are searching for care solutions that may relieve them of financing burdens. This could imply a changing mix between core institutions of welfare production, encompassing

7  Policy Responses to Aging: Care Services for the Elderly in Norway

113

trajectories of change in the division of care labour, responsibility and costs between family, market, state and the voluntary sectors, e.g. critical and crucial questions in defining the normative content and redistributive ambitions of the welfare state (Daly & Lewis, 2000). The arguments for changing the organization of welfare services, especially towards increasing reliance on market and civil society actors include much more than needs for shifting the burden away from the state. Cost efficiency, quality enhancements, provision of individual choice options and potential for innovation have been some elements in the debate. A significant change over the last decades in many countries has been towards the increasing marketization of care. Marketization is defined by the presence of market rationalities and practices (Anttonen & Meagher, 2013). Within Scandinavian eldercare, Sweden has spearheaded the development towards marketization. During the 1990s, private provision (figures including both for- and non-profit providers) of elderly care and for people with disabilities, measured in terms of private employment increased from 3 to 13% of the workforce. The marketization processes continued into the next decade so that by 2012, 21% of beds in residential care and 23% of home care hours were provided by private providers (Erlandsson et  al., 2013, p. 23). Most of the growth has been in the for-profit providers as measured by staff figures. Moreover, according to these authors the coverage of needs assessed eldercare has fallen behind the growth of the elderly population. A similar strong trend towards marketization is not observed so far in the Norwegian context; the voluntary sector’s share remains stable, whereas a slightly growing share for private for-­ profit provision is discernible (Statistisk sentralbyrå, 2014b; Vabø, Christensen, Jacobsen, & Trætteberg, 2013). In Denmark, marketization principles started with the introduction of the purchaser-provider model in 1996, and outsourcing of home care for-profit providers took off from 2003 with the introduction of the ‘Free choice of Provider Scheme’ (Bertelsen & Rostgaard, 2013). It requires local authorities to encourage alternative service provision from for-profit providers and in 2012 around 1/3 of home care users had for-profit providers (op. cit. p. 146). In Nordic comparisons, Denmark has a long and strong tradition of involving non-profit service providers, and this is a tradition which still remains stable. Ideal institutions performed 14% of the welfare services in Denmark in 2004. Twenty percent of the nursing homes for elderly are non-governmental (Sivesind, 2013). Table 7.1 provides information on the relative role of non-profit and for-profit provision in elderly care (home care and residential care) in the three Scandinavian countries: As noted by the authors there is a lack of good statistics to describe the welfare mix in individual countries as well to provide comparable statistics in a S ­ candinavian/ Nordic and European (cf. also Table 7.2) context. With these caveats in mind, there seems to be some clear tendencies in that Sweden has so far experienced the strongest impact of marketization, whereas Denmark occupies a middle position and particularly Norway has been less affected (Szebehely & Meagher, 2013). Norway stands out as an exception from the other Scandinavian countries, by not having introduced tax rebates for household services and care, and for favouring non-profit providers since 2006 as part of its public procurement legislation.

FP for-profit, NP non-profit Source: (Szebehely & Meagher, 2013: Table 1, pp. 244–245). For detailed information on sources and calculations cf. op.cit, pp. 243–249

Table 7.1  Welfare mix of for-profit and non-profit in eldercare services in Scandinavian countries, 2000–2012 Around 2000 Around 2012 Norway Home care (% of expenditure) 3.1% FP, 0% NP (home help); 0.2% FP, 0.1% NP (home nursing) Residential care (% of expenditure) 3.5% FP, 5.9% NP (% of beds) 10.7% (FP+NP) 9.6% (FP+NP) Eldercare and disability services (combined) 6.6% of working hours (FP+NP); 8.1% of expenditure (FP+NP) Denmark Home care (% of FP users) 2.5% of users 47% of users of practical assistance only 31% of users of both practical help and personal care 6% of users of personal care only 37% of all home care users; 13% of all home care hours Residential care (% of residents) Less than 1% (around 2005) Less than 1% FP (no information on NP) Eldercare total (% of staff hours) 5–6% FP (no information on NP) Sweden Home care (% of hours) 7% (FP+NP) 21% FP, 2% NP Residential care (% of residents) 12% (FP+NP) 18% FP, 3% NP Eldercare and disability services total (% of staff) 8% FP; 3% NP 17% FP; 3% NP (2010)

114 R. Ervik

Public

LTC users per full-time worker in home care LTC users per full-time worker in institutional care Institutional mix of formal provision of services

Public LTC expenditure, percentage of GDP Sources of funding

6.3a Strong degree of private for-profit provision

1.3

Strong and dominant public sector provision

Nursing homes: 91.1% Home care: 93.2%

Nursing homes: 6.0% Home care: 24% (includes non-profit)

Public financing: approx. 50% Private household out of pocket: approx. 50% –

General gov. taxes: 89.3% Private household out of pocket: 10.7%

4.7

0.8

2.2

Table 7.2  Care regimes: dimensions and indicators on institutional responsibility in Norway, UK and Germany Mixed/hybrid system of means-tested LTC and Universal tax-funded universal NHS (individualist/ model, with public family centred) provision (state centred) Type of care regime Country examples Norway UK Dimensions and indicators Mix of personal and state Responsibility for financing Public tax financing responsibility, low to medium and pooling of resources indicates high degree of degree of resource pooling resource pooling

(continued)

Fairly equal mix of private for-profit and non-profit voluntary organization, marginal role of public Nursing homes: 7.0% Home care: 2.0%

2.3

General gov. taxes: 12.5% Social security funds (LTC Insurance): 54.7% Private household out of pocket: 30.4% 12.9

Social insurance based, with state subsidies and substantial degree of private payments, medium degree of resource pooling 0.9

Family centred and insurance based Germany

7  Policy Responses to Aging: Care Services for the Elderly in Norway 115

42% unpaid family LTC workers. 58% formal LTC workers

Non-profit, voluntary organization

Role of unpaid family care: unpaid workers as percentage of total LTC workers/providers

Mixed/hybrid system of means-tested LTC and universal NHS (individualist/ family centred) Nursing homes: 81.0% Home care: 76% Nursing homes: 13.0% Home care: 24% (includes public) 81% unpaid family LTC workers. 19% formal LTC workers 70–80% of care provided within familiesb

Family centred and insurance based Nursing homes: 37% Home care: 55% Nursing homes: 56% Home care: 43%

Source: This table is based on selected information adopted from Ervik et al. 2013, table 10.1, pp. 236-238. For detailed information on sources, cf. op.cit, p. 238 a Figures refer to ratio of care recipients aged over 65 to LTC workers in institutions for the year 2004 b For Germany no separate estimate has been identified. Here information on non-Nordic countries as provided in Österle and Rothgang (2010: 384) is applied

Type of care regime Private for-profit

Universal tax-funded model, with public provision (state centred) Nursing homes: 4.1% Home care: 6.8% Nursing homes: 4.8% Home care: 0.0%

Table 7.2 (continued)

116 R. Ervik

7  Policy Responses to Aging: Care Services for the Elderly in Norway

117

Even though national statistics in the Norwegian case indicate smaller changes, it is important to be reminded of the centrality of the local level in deciding the part of the welfare mix concerned with the role of public versus profit and non-profit provision. Exploring the local level reveals more variation between municipalities towards marketization tendencies. In many municipalities, home care and residential care are still delivered exclusively by the local authorities. Marketization is more extensive in some larger cities. Thus, in Oslo around 16% of nursing homes are operated by private commercial companies and within home care 21.8% of the users have chosen private enterprises (NHO Service, 2010, p. 9). The policy of exposing elderly care services to competition is politically contested in Norway. At the national level, there is a traditional divide between political parties on the left and right. The left is highly sceptical of letting profit seeking commercial actors into this field. A key argument is that because care services are labour intensive, the only way to make a profit on publicly financed services is by reducing wages, pensions, staff and working conditions for those employed in these companies. The political right argues in favour of allowing private for-profit providers, because it in their views secures free user choice, leads to cost reductions and improves the quality of care. Public opinion is also highly divided. Thus in a survey of the 2005 parliamentary election 45% agreed fully or to some extent with the general view that many public activities could have been performed both better and less expensive if they were undertaken by private sector companies. Forty eight percent of respondents disagreed fully or to some extent (Aardal, 2007). However, the 2013 election witnessed a turn in the opinion towards favouring market solutions to a stronger degree, with 56% agreeing fully or to some extent that private undertaking would improve quality and be less expensive than public activities (Kleven, Aardal, Bergh, Hesstvedt, & Hindenes, 2015). So far there is limited evidence of the consequences of marketization of elderly care in Norway. Summing up the evidence so far, Szebehely and Meagher (2013) find that in terms of costs saving a study of Oslo finds lower costs for outsourced nursing homes (residential care), but transaction costs are not included. Regarding quality of users no differences in user satisfaction is found in the Oslo study. For employment and working conditions cost saving strategies are likely to affect workers, i.e. since pension agreements in FP care are less generous than in public municipal and NP sector schemes, and indications of lowered staffing levels resulting from FP takeovers. For home care services no studies are reported on cost savings, but there are findings from case studies suggesting that stricter regulation of care tasks has impacted negatively on care workers possibility to flexibly respond to complex and shifting care needs. Importantly this also affects publicly employed workers. Whereas there is heated debate on profit based elderly care provision, the promotion of voluntarism and the non-profit sector as well as improving support for safeguarding family care enjoys a broad political consensus. The committee on innovation in care recommends as a specific aim to increase the role of the voluntary sector (voluntary activities, user-governed co-ops, social firms, social entrepreneurship establishments) so that by 2020, 25% of the total activity in the care sector is organized and run as voluntary activities/enterprises (NOU, 2011, p. 54). The share

118

R. Ervik

of the voluntary sector in 2012 is approximately 5%. Thus, in relative terms, to an increasing extent LTC will be provided by voluntary organizations of different forms. A keyword is so-called co-creation, which represents a mix of activities by both public service agents and citizens to provide public services (NOU, 2011, p. 55). A critical question is whether this substantial increase in voluntary activity is feasible, given that other welfare reforms within the labour market and pensions increase the importance of active labour market participation and the prolongation of working careers to secure income and future pension benefits. Thus, in terms of financing, the public sector will need to play an important role in securing the economic foundation for expansion of the voluntary sector. It seems highly unlikely that other forms of financing such as donations, gifts and unpaid voluntary work can provide more than a small fraction of the costs of LTC (Ervik et al., 2013, p. 250).

7.7  Innovations in Care: Welfare Technology in Elderly Care Service production including elderly care services are highly labour intensive. An aging population suggest that in the future a larger share of the labour force will have to work in this sector. Projections of future employment in the health and long term care sector assuming 1% yearly standard growth of services, unchanged level of informal care and constant age specific health status, conclude that more than 1/3 of the total number of man-years will work in this sector by 2060, up from around 11% in 2010 (Holmøy et al., 2014).The traditional understanding points out that the production of services are labour intensive and that new technological progress that can improve productivity is less important within that sector. This perspective on slow productivity growth within the service sector has been applied as one of several factors explaining welfare state change in terms of ‘permanent austerity’ (Pierson, 1998, pp. 541–545). A basic premise with broad consensus among economists is that ‘service production is inherently less conductive to productivity growth’ (Iversen & Wren, 1998) (op.cit: 511). Thus addressing the cost-disease and service expansion Gösta Esping-Andersen states: ‘Many services, such as music concerts, psychotherapy or aged care, are capable of almost no productivity enhancement (at least not without a quality loss)’ (Esping-Andersen, 1999, p. 111). The introduction of welfare technology could be seen as a way to confront the above static and pessimistic view. In brief, welfare technology may ease the burden of old age dependency by enhancing the capacity of those providing care services and at the same time reduce the need for assistance of those defined as ‘dependent’. The green paper on innovation in care defines welfare technology as technological assistance that contributes towards increased security, social participation, mobility and physical and cultural activity. It strengthens the person’s ability to manage his or her daily life, despite sickness, and social, psychic or physical reductions of functional abilities (NOU, 2011, p. 11, 99). The range of relevant technologies in care services covers security technology, compensation and well-being technology, social

7  Policy Responses to Aging: Care Services for the Elderly in Norway

119

contact technology and technology for treatment and care.12 Some of the technologies are known and mature (for instance, safety alarms and fall sensors), others are in a developmental stage expected to be implemented in the future (e.g. personal cleaning robots, ‘knowing’ where it is and able to clean the complete dwelling, expected to be available after 2020) (cf. op.cit. pp. 101–113). One way of assessing the effect of technological innovations in the care sector is to study its potential for reducing demand for labour power. Rambøll management made an analysis for the elderly care sector in Denmark based on the implementation of known and mature technologies (Rambøll Management, 2007). These included introduction and integration of information technology to support elderly care, video consultations in wound treatment, and increase of own care by the use of blood pressure measurement and other instruments for people within the stroke risk group. The labour saving effect of introducing these technologies in the period 2007–2020 amounted to around 6500 FTE as compared to a situation where no investments in technology were made. Thus, whereas the need for employment would grow from 106,000 in 2007 to 118,000 in 2020, without any investment in care technology, the same growth with care technology investment would require 111,500 in 2020. Thus the growth in employment over the period was reduced by 46% by introducing these mature technologies. Or alternatively, the employee growth over the period would be 11.3% in the first scenario (without technology), but only 5.2% in the alternative situation of implementing technology. Another analysis by KMD Analyse (2010) assess that 20% of the care services sector tasks can fully or partly be solved by welfare technology. In a wider economy context and also including non-mature technologies, Frey and Osborne (2013) examined how susceptible jobs are to be computerized in the USA including 702 detailed occupations, covering 97% of total employment.13 According to their estimates, around 47% of total US employment is at risk of being computerized.14 The figures on computerization taken from the USA are probably not directly transferable to a European, Scandinavian or Norwegian context. As noted by the authors, labour saving inventions may only be adopted if the access to cheap labour is scarce or prices  Here welfare technology may assist and enable individuals to postpone need for LTC services or reduce the scope of services needed when a care need manifests itself. An imaginative illustration of this is exoskeleton technology that may be applied to avoid fall risks, and as a way to retrain and augment muscle force in case of a fall accident (Helsedirektoratet, 2012, p. 11). In general, exoskeletons and robotic prosthetics may enhance the ability of physically disabled and elderly to lead healthier and less restricted lives (MGI, 2013, p. 68). 13  The authors define computerization as: ‘job automation by means of computer controlled equipment’ (op.cit, p. 2). 14  The definition of welfare technology above excludes developments in other technology fields that may impact care services, for instance practical daily tasks of home care. Changes in material technology and the use of nano-technology is illustrative. A familiar example would be window cleaning. This is a field where routine activity of human window cleaning personnel has a high probability of computerization. However given innovations in material characteristics, for instance, self-cleansing windows, the need for computerization may become void. Otherwise, combining both new material technology and computerization may boost the labour saving effect of technology [Cf. also Ministeriet for Videnskab Teknologi og Udvikling, 2006, p. 14]. 12

120

R. Ervik

of capital are relatively high. Thus how wages are negotiated within the LTC care sector may be one critical factor for the extent to which it contributes to or inhibits the deployment of labour saving technology. If the sector is dominated by low pay work, there may be few incentives for substituting workers with technology. Such a development would represent a break with the Nordic model of wage settlement and lead to a low cost road to care services. Technological innovations are promising in terms of improving the quality of care, possibly reducing the labour intensity of the sector and easing the physical burden of care work for employees, family and volunteers. However, technology in itself cannot solve or remove the social and normative questions concerning redistribution and social rights within elderly care. Depending on policy choices welfare technology may become a new driver of inequality and divisions between poor and rich people within countries, as well as between rich and poor countries. This is to be addressed further in the conclusive discussion below.

7.8  Conclusive Discussion The brief history of the Norwegian elderly care sector, and particularly in the period 1965–1980, reveals that major social changes, described as ‘the public revolution’, may take place in a short time period. It represented a clear shift of responsibility away from the family towards the public sector, to cover the risks of old age care needs. Underpinning this has been the general universal normative basis of the Nordic welfare states (Kildal & Kuhnle, 2005). The service universalism encompasses publicly financed services available to all citizens according to their needs rather than their ability to pay. This said as an important context for asking the question in the introduction on what could be relevant from these experiences when developing services for the elderly in other countries. The point being that in order to decide what is relevant we need first to address the normative questions on whether the risk of care needs in old age is mainly a public responsibility, and if its provision ought to include all citizens on equal terms. Subscribing or not to these basic normative statements will impact on the relevance of the service universalism characterizing the Nordic countries for other countries in the process of building their elderly care services. Key elements in this care model are a tax financed system of predominantly publicly provided services at the local level. It is also important that the quality of services is s­ ufficiently high as to integrate the middle class and provide legitimacy to the system, even though the price to pay is a high tax level. Population aging represents a challenge to the elderly care system and a need to provide innovations to build a care sector for the future. This paper has briefly described a few elements of this policy debate and so does not pretend to give the full picture. In discussing examples of innovations, these have included both changes in working methods towards active care (daily life rehabilitation and attending to cultural needs of elderly) as well as the potential use of welfare technology

7  Policy Responses to Aging: Care Services for the Elderly in Norway

121

in care. They are all important since they address very concrete problems with an increased risk of occurrences as we age: falls and reduced physical abilities, loneliness and cognitive impairment. Combining these different innovations in care services are likely to bring results that supports the relative independence and well-being of older people. Insisting on keeping welfare technology outside the elderly care area for fears of replacing ‘warm hands’ of care with ‘cold technology’ is therefore misguided. In terms of the welfare mix, we have seen that Scandinavian countries have entered different paths, with Sweden increasingly relying on marketization of care services. The outcome of this for the sustainability of service universality is uncertain. Some researchers worry that there may be developments towards a dualization of care, because of cutbacks in residential care beds not compensated by increase in home care. This leads to increase in family care particularly by daughters with less education, not able to buy additional services at the care market (Ulmanen & Szebehely, 2015). This perspective is also relevant when considering the use of welfare technology and the importance of political choices to avoid new social divisions of welfare. In the absence of an active state in financing and distributing welfare technology on a universal basis, there is a risk that these innovations only will benefit a privileged minority reflecting the unequal ability to pay. A final point to make is that an active state is needed to make future innovations in welfare technology possible. As Mazzucato (2013) reveals, the state historically and today continues to play an entrepreneurial role in making things happen, by setting up a mission and investing boldly even in face of great uncertainties. This has brought great advances in technology that later on has been incorporated into commercial products (for instance, US state investments underpinning the development of iphone, op.cit, pp.  87–112). Welfare technology should be another field where this entrepreneurial role is needed.

References Aardal, B. (2007). Saker og standpunkter. In B. Aardal (Ed.), Norske velgere. En studie av stortingsvalget 2005. Oslo: Damm. Anttonen, A., & Meagher, G. (2013). Mapping marketisation: Concepts and goals. In G. Meagher & M.  Szebehely (Eds.), Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences (Stockholm Studies in Social Work 30) (pp. 13–22). Stockholm: Department of Social Work, University of Stockholm. Bambra, C. (2007). Defamilisation and welfare state regimes: A cluster analysis. International Journal of Social Welfare, 16(4), 326–338. https://doi.org/10.1111/j.1468-2397.2007.00486.x Bertelsen, T.  M., & Rostgaard, T. (2013). Marketisation in eldercare in Denmark: Free choice and the quest for quality and efficiency. In G. Meagher & M. Szebehely (Eds.), Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences (Stockholm Studies in Social Work 30) (pp. 127–160). Stockholm: Department of Social Work, University of Stockholm. Colombo, F., Llena-Nozal, A., Mercier, J., & Tjadens, F. (2011). Help wanted? Providing and paying for long-term care. Paris: OECD Publishing.

122

R. Ervik

Cook, I.  G., & Halsall, J.  (2012). Aging in comparative perspective: Processes and policies. Boston: Springer. Daly, M., & Lewis, J. (2000). The concept of social care and the analysis of contemporary welfare states. British Journal of Sociology, 51(2), 281–298. Danielsen, H. (2015). Det lange 70-tallet 1960-1990. In H. Danielsen, E. Larsen, & I. W. Owesen (Eds.), Norsk likestillingshistorie (pp. 154–185). Bergen: Fagbokforlaget. Erlandsson, S., Storm, P., Stranz, A., Szebehely, M., & Trydegård, G.-B. (2013). Marketising trends in Swedish eldercare: Competition, choice and calls for stricter regulation. In G. Meagher & M. Szebehely (Eds.), Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences (Stockholm Studies in Social Work 30) (pp. 23–83). Stockholm: Department of Social Work, Stockholm University. Ervik, R., Helgøy, I., & Lindén, T. S. (2013). Strategies to meet long-term care needs in Norway, the UK and Germany: A changing mix of institutional responsibility. In R.  Ervik & T.  S. Lindén (Eds.), The making of ageing policy: Theory and practice in Europe (pp. 231–256). Cheltenham: Edward Elgar. Esping-Andersen, G. (1999). Social foundations of postindustrial economies. Oxford: Oxford University Press. Estes, R. J., & Zhou, H. (2015). A conceptual approach to the creation of public-private partnerships in social welfare. International Journal of Social Welfare, 24(4), 348–363. Eurostat. (2011). The greying of the babyboomers. A century-long view of ageing in European populations. Brussels: European Commission. Frey, C.  B., & Osborne, M.  A. (2013). The future of employment: How susceptible are jobs to computerisation? Oxford: Oxford Martin School, University of Oxford. Gautun, H., & Grødem, A.  S. (2015). Prioritising care services: Do the oldest users lose out? International Journal of Social Welfare, 24(1), 73–80. https://doi.org/10.1111/ijsw.12116 Hauglum, S. (2012). “Vossamodellen” kvardagsrehabilitering på Voss. Ergoterapeuten, (1), 19–22. Helsedirektoratet. (2012). Velferdsteknologi: Fagrapport om implementering av velferdsteknologi i de kommunale helse- og omsorgstjenestene (pp. 2013–2030). Oslo: Helsedirektoratet. Holmøy, E., Kjelvik, J., & Strøm, B. (2014). Behovet for arbeidskraft i helse- og omsorgssektoren fremover. Oslo: Statistisk Sentralbyrå (SSB). Høyskolen i Bergen. (2015). Vossamodellen–hverdagsrehabilitering. Retrieved April 18, 2015, from http://www.hib.no/forskning/om-forskning/ahs/vossamodellen/. Innst. 477 S. (2012–2013). Innstilling til Stortinget fra helse-og omsorgskomiteen Meld. St. 29 (2012-2013) Innstilling fra helse- og omsorgskomiteen om morgendagens omsorg. Iversen, T., & Wren, A. (1998). Equality, employment, and budgetary restraint: The trilemma of the service economy. World Politics, 50(4), 507–546. Kildal, N., & Kuhnle, S. (Eds.). (2005). Normative foundations of the welfare state. The Nordic experience. London: Routledge. Kleven, Ø., Aardal, B., Bergh, J., Hesstvedt, S., & Hindenes, Å. (2015). Valgundersøkelsen 2013. Dokumentasjons- og tabellrapport. Oslo: SSB. KMD Analyse. (2010). Digitalisering af ældreplejen. Potentialer og holdninger. Copenhagen: KMD Analyse. Le Feuvre, N., Ervik, R., Krajewska, A., & Metso, M. (2012). Remaking economic citizenship in multicultural Europe: Women’s movement claims and the ‘commodification of elderly care’. In B. Halsaa, S. Roseneil, & S. Sümer (Eds.), Remaking citizenship in multicultural Europe (pp. 70–93). Basingstoke: Palgrave Macmillan. Mazzucato, M. (2013). The entrepreneurial state. Debunking public vs. private sector myths. New York: Anthem Press. Meld. St. 29. (2012–2013). Morgendagens omsorg. Oslo: Helse- og omsorgsdepartementet. MGI. (2013). Disruptive technologies: Advances that will transform life, business and the global economy. McKinsey Global Institute Technology report, Seoul Ministeriet for Videnskab Teknologi og Udvikling. (2006). Teknologisk fremsyn: Om kognition og robotter. København: Ministeriet for Videnskab, Teknologi og Udvikling.

7  Policy Responses to Aging: Care Services for the Elderly in Norway

123

Mørk, E., Beyrer, S., & Haugstveit, F. V. (2016). Kommunale helse- og omsorgstjenester 2015. Statistikk om tjenester og mottakere. Oslo: SSB. Mørk, E., Sundby, B., Otnes, B., & Wahlgren, M. (2014). Pleie- og omsorgstjenesten 2013. Statistikk om tjenester og tjenestemottakere. Oslo: SSB. Næss, S. (2008). The provision of social care services to the elderly. A Scandinavian perspective. In M. Olivier & S. Kuhnle (Eds.), Norms and Institutional design. Social security in Norway and South Africa (pp. 231–240). Stellenbosch: Sun Press. Nagel, A.-H. (Ed.). (1991). Velferdskommunen. Kommunenes rolle i utviklingen av velferdsstaten. Bergen: Alma Mater. NHO Service. (2010). Omsorgstjenester. Bransjestatistikk 2010. Oslo. Norges Bank. (2015). Valutakurser. Retrieved April 9, 2015, from Norges Bank http://www. norges-bank.no/Statistikk/Valutakurser/valuta/CNY/. Norwegian Ministry of Health and Care Services. (2014). Egenbetaling for kommunale tjenester i og utenfor institusjon. Oslo: Helse-og omsorgsdepartmentet. Retrieved from https://www. regjeringen.no/nb/tema/helse-og-omsorg/helse%2D%2Dog-omsorgstjenester-i-kommunene/ innsikt/egenbetaling-i-og-utenfor-institusjon/id434597/. NOU. (2011). Innovasjon i omsorg. Oslo: Helse-og omsorgsdepartementet. OECD. (2006). Live longer, work longer. Paris: OECD Publishing. OECD. (2011). Pensions at a glance 2011. Paris: OECD Publishing. OECD. (2015). Database on social expenditure. Paris: OECD.  Retrieved 22 April, 2015, from https://stats.oecd.org/Index.aspx?DataSetCode=SOCX_AGG. Österle, A., & Rothgang, H. (2010). Long-term care. In F.  G. Castles, S.  Leibfried, J.  Lewis, H.  Obinger, & C.  Pierson (Eds.), The oxford handbook of the welfare state (pp.  405–417). Oxford: Oxford University Press. Pierson, P. (1998). Irresistible forces, immovable objects: Post-industrial welfare states confront permanent austerity. Journal of European Public Policy, 5(4), 539–560. Rambøll Management. (2007). Omsorgsteknologi kan give mere tid til pleje i ældresektoren. København: Rambøll Management. Reisel, L., & Teigen, M. (2014). Kjønnsdeling og etniske skiller på arbeidsmarkedet. Oslo: Gyldendal akademisk. Romøren, T.  I. (2011). Helse. og omsorgstjenesten i kommunene. In A.  Hatland, S.  Kuhnle, & T. I. Romøren (Eds.), Den norske velferdsstaten (pp. 199–226). Oslo: Gyldendal Akademisk. Seip, A.-L. (1994). Veiene til velferdsstaten. Norsk sosialpolitikk 1920–1975. Oslo: Gyldendal Norsk Forlag. Sivesind, K. H. (2013). Ideella välfärdstjänster: En lösning på den nordiska modellens framtidiga utmaningar? In L. Trägård, S. L. Henriksen, P. Selle, & H. Halén (Eds.), Civilsamhället klämt mellan stat och kapital: Velferd, mångfald, framtid (pp. 75–88). Stockholm: SNS förlag. St.forh. (2012–2013). Sak nr. 9 innstilling fra helse-og omsorgskomiteen om morgendagens omsorg (Innst. 4777 S (2012–2013), jf. Meld.St. 29 (2012–2013)) (pp. 4386–4401). St.meld.nr. 25. (2005–2006). Mestring, muligheter og mening, Omsorgsplan 2015. Oslo: Helse- og omsorgsdepartementet. Statistisk Sentralbyrå. (1978). Historisk statistikk 1978 (Historical statistics 1978). Oslo: SSB. Statistisk sentralbyrå. (2014a). Folkemengde, 1. januar 2014. Oslo: SSB.  Retrieved March 27, 2015, from http://ssb.no/befolkning/statistikker/folkemengde/aar/2014-02-20?fane=tabell&so rt=nummer&tabell=164158. Statistisk sentralbyrå. (2014b). Inntekts- og formuesstatistik for husholdninger, 2013. Oslo: SSB. Retrieved April 22, 2015, from https://www.ssb.no/inntekt-og-forbruk/statistikker/ifhus/ aar/2014-12-17. Statistisk sentralbyrå. (2014c). Satelittregnskap for ideelle og frivillige organisasjoner, 2012. Kongsvinger: SSB.  Retrieved December 11, 2014, from https://www.ssb.no/ nasjonalregnskap-og-konjunkturer/statistikker/orgsat/aar/2014-12-03#content. Statistisk sentralbyrå. (2015). Historisk statistikk. Folkemengde i viktige aldersgrupper. Oslo: SSB. Retrieved April 22, 2015, from https://www.ssb.no/a/histstat/tabeller/3-5.html.

124

R. Ervik

Szebehely, M., & Meagher, G. (2013). Four Nordic countries - Four reponses to the international trend of marketisation. In G. Meagher & M. Szebehely (Eds.), Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences (pp.  241–288). Stockholm: Stockholm Universiyt, Department of Social Work. Ulmanen, P., & Szebehely, M. (2015). From the state to the family or to the market? Consequences of reduced residential eldercare in Sweden. International Journal of Social Welfare, 24(1), 81–92. https://doi.org/10.1111/ijsw.12108 UNECE United Nations Economic Commission for Europe. (2007). Proceedings from the 2007 Ministerial Conference on Ageing (Conference Report, 6–8. November 2007 León, Spain). Retrieved from León. Vabø, M., Christensen, K., Jacobsen, F. F., & Trætteberg, H. D. (2013). Marketisation in Norwegian eldercare: Preconditions, trends and resistance. In G.  Meagher & M.  Szebehely (Eds.), Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences (pp. 163–202). Stockholm: Department of Social Work, University of Stockholm. Vabø, M., & Szebehely, M. (2012). A caring state for all older people? In A. Anttonen, L. Häikiö, & K. Stefánsson (Eds.), Welfare state, universalism and diversity (pp. 121–143). Cheltenham: Edward Elgar. Välfärdscenter, N. (2010). Fokus på Velfærdsteknologi. Stockholm: Nordens Välfärdscenter. Walker, A., & Foster, L. (2013). Active ageing: Rhetoric, theory and practice. In R. Ervik & T. S. Lindén (Eds.), The making of ageing policy. Theory and practice in Europe (pp.  27–52). Cheltenham: Edward Elgar. World Health Organization. (2002). Active ageing. A policy framework. Geneva: World Health Organization.

Chapter 8

Is Finland Connected for e-Health and e-Welfare? Minna Zechner

8.1  Introduction Finland is often seen as one of the Nordic welfare societies that are characterized by social solidarity, the universality of social programs, and a high level of social protection (Bertilsson & Hjorth-Andersen, 2009; Ervasti, Friberg, Hjerm, Kangas, & Ringdal, 2008). A particular feature of the Nordic welfare model is, or at least has been, the central role of the public, needs-tested social and healthcare services, together with a strong involvement of municipalities or counties in the organization and production of these services (Cox, 2004; Meagher & Szebehely, 2013; Van Aerschot & Zechner, 2014). Even though the basic idea of a strong welfare state still persists in Finland, Juho Saari (2017) has called the past decade the “cold era of social policy” (sosiaalipolitiikan kylmä kausi), by which he means the economic crisis which has been followed by cuts in welfare spending that are resulting in increasing inequalities and negative consequences, especially among the most marginalized groups. Limiting the spending on welfare has not been the only response to the challenges caused firstly by the economic downturn, and secondly by an aging Finnish population. Massive changes in the structure and organization of local democracy are under way, affecting both social services and healthcare. Until the end of 2020, the organization of social and healthcare services is the responsibility of local municipalities (which number 311 in 2017), but from 2021 onwards, this responsibility is planned to be restructured to 18 counties. At present, municipalities have the responsibility to organize social and healthcare services, but not necessarily to

M. Zechner (*) University of Lapland, Rovaniemi, Finland e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_8

125

126

M. Zechner

provide them. Both public and private (for-profit and non-profit) actors currently provide services, and this will continue in the future when counties adopt their new roles. In 2016, private entities provided approximately 25% of the publicly funded social and health services. In this article, public services or publicly funded services are considered as those that are organized by municipalities and funded predominantly from the public purse. In 2014, the public funding of healthcare covered 76% and private funding 24% of associated costs (Matveinen & Knape, 2016). The main funders of social security were public actors, the state and municipalities (47% of costs), and employers (34% of costs). Service users covered 13% of costs (Sosiaaliturvan menot ja rahoitus 2015, 2017). When the counties take on the responsibility to organize services, municipalities will continue to exist, but will have fewer tasks in relation to social and health issues, for example, those relating to the handling of employment issues, promoting competence and culture, health, and wellbeing, and the responsibility for sports, youth, cultural, and other leisure services (Health, Social Services and Regional Government Reform, 2017). This restructuring takes place in an era of low economic growth, population aging, and restricted spending, and aims to create efficiency and savings in public spending. In 2015, social and health expenditure accounted for nearly 32% of Finland’s gross national product (GNP). These reforms rest not only on the shifting of certain responsibilities from smaller municipalities to larger counties, but also feature the digitalization of social and health services as an essential component. The aim is that information and communication technologies (ICT) and e-Services support both the service users and professionals who work in the services. The idea is to produce new and efficient services such as e-Services, and ensuring that these services are also available in sparsely populated areas. Especially, e-Services are also seen as offering citizens more possibilities to maintain their own health and wellbeing (Health, Social Services and Regional Government Reform, 2017). This article focuses on e-Welfare and e-Health in Finland. e-Welfare and e-Health are parallel terms that mean the use of information and communication technology locally and also at distance in social and healthcare (Hyppönen, Hämäläinen, & Reponen, 2015). These may range from, e.g., using electronic client and patient records to even performing operations with the help of robots across a distance. This article focuses on the general trends in e-Welfare and e-Health in Finland, hence these broad concepts are adequate. The main aim of this article is to describe the policy goals of e-Welfare and e-Health in Finland, to assess current experiences using e-Welfare and e-Health case studies, and to evaluate the possibilities and expectations placed on e-Welfare and e-Health services. Notably, the focus of the article is at a policy level, and on user-related approaches and experiences, rather than technical issues and solutions.

8  Is Finland Connected for e-Health and e-Welfare?

127

8.2  Policy-Level Aims of e-Welfare and e-Health in Finland The reasons for the digitalization of social and healthcare in Finland are stated in various documents. In relation to the government reform where many responsibilities are transferred from municipalities to counties, digitalization aims to increase the accessibility and equality of services (Health, Social Services and Regional Government Reform, 2017). The Finnish Ministry of Social Affairs and Health policy for digitalization (Digitalisaatio terveyden ja hyvinvoinnin tukena, 2016) sees digitalization as one of solutions for the following challenges. Firstly, the promotion of wellbeing and health in an aging population needs more support, immigrants are a new and specific group of service users. Together with the growing deficit in public sector spending, this means that this increasing demand must be met with diminishing economic resources, requiring services to be more productive, efficient, and cost-effective. Additionally, customers are more demanding than in earlier times, and for the new generations, the development of digital services is self-evident. In policy and strategy texts, digitalization, e-Welfare, and e-Health are generally presented as inevitable and positive developments. The Finnish Ministry of Social Affairs and Health policy for digitalization (Digitalisaatio terveyden ja hyvinvoinnin tukena, 2016) claims that Finland is one of the leading countries in electronic data management in welfare and health fields. As an evidence, the policy refers to Kanta, the national data system service for healthcare services, pharmacies, and citizens. They include electronic prescription services, a Pharmaceutical Database, “My Kanta” pages, and a Patient Data Repository. My Kanta is the user interface for citizens, where they can see their own healthcare data and determine what levels of information they wish to be made available to different service providers. These areas are hosted by the Social Insurance Institution of Finland (Kela). Another example offered is The Enterprise Finland portal that assists employers in health and safety at work. The European Commission publishes a Digital Economy and Society Index (DESI1), which is a composite index measuring the progress of EU countries towards a digital economy and society. In 2016, Finland was at the top of the list, and in 2018 it is placed third after Denmark and Sweden (European Commission 2018). Reading the policy documents and research, it becomes evident that digitalization is more advanced in the field of health than in social services. One explanation for the slower advancement of e-Welfare may be that compiling common electronic client data systems is difficult, especially given that agreeing on issues even as elementary as how to refer to users of social services is a challenge. Social services cover a wide array of services, such as child welfare, care of older people, and adult  DESI measures connectivity (fixed broadband, mobile broadband, broadband speed, and prices), human capital (basic skills and internet use), advanced skills and development, use of internet (citizens’ use of content, communication, and online transactions), integration of digital technology (business digitization and e-Commerce) and digital public services (e-Government). 1

128

M. Zechner

social work. The development work needed for the common concepts and understanding of client records is under way (see for example: Sosiaalialan ­tiedonhallinnan sanasto, 2017). Several efforts (including the National Project for IT in Social Services 2005–2011 organized by the Ministry of Social Affairs and Health) have been made to standardize data processing and the structure of documents in social welfare (Laaksonen & Ailio, 2011), and similar kinds of work have also been undertaken in healthcare services. The need for structured data instead of narrative text in patient records was pointed out in early Finnish e-Health strategy documents in 1998 (Hyppönen et al., 2017). At some point in the future, based on jointly defined concepts, the digital Kanta healthcare system is aimed to be developed to provide a SosKanta system, where social service client data will be added. The first social service client documents are planned to be entered into the national data repository in 2018–2020, and clients would be able to access their documents in 2020. The first documents to be entered will not be structured, but the structural elements will gradually be increased (Hämäläinen & Reponen, 2015). An existing, development in Finnish e-Welfare is the digitalization of social assistance applications and the handling system at the Social Insurance Institution of Finland (Kela). When the national systems of Kanta and SosKanta are available with a social assistance system, a massive and easily accessible social and healthcare client data base will be generated for use. As many systems that relate to client records (at least in healthcare) are already or close to being in place, the Ministry for Social Affairs and Health has shifted its policy focus from storing data to using it. This reflects the use of data in various ways: by patients, treating professionals, managers of services, and researchers (Tieto hyvinvoinnin ja uudistuvien palvelujen tukena, 2015). This is also the recommendation of the Nordic e-Health Research Network (NeRN), founded in 2012 under the Nordic Council of Ministers. NeRN reports that the secondary use of health data is also a high priority for the Organisation for Economic Co-operation and Development (OECD), the European Union (EU) and in a range of Nordic e-Health policies. In order for this to be possible, privacy concerns and the trust of populations related to the governance of their health data are key elements. Additionally, the interoperability and quality of data are seen as important concerns (Hyppönen et al., 2017). At the Finnish level, strategic goals are set so that the data gathered from social and health service users can be used for increasing their wellbeing and for developing better services (Tieto hyvinvoinnin ja uudistuvien palvelujen tukena, 2015). The first aim of the strategy is that citizens have the possibility to use the data for self-­ care. In addition, the strategy leans towards information systems and electronic applications that support the work of professionals in increasing service efficiency. Finally, the data is used for decision-making, management, innovation, industrial and commercial activity, and research. This is all intended to be achieved in a nationally synchronous way, so that data is commensurable and the systems and applications are compatible. Hyppönen et al. (2017) have noted that in relation to e-Health in the Nordic countries, there is a shift away from an emphasis on technical infrastructure, and towards stressing the importance of governance and stakeholder involvement, and keeping business support as an important strategic target.

8  Is Finland Connected for e-Health and e-Welfare?

129

In addition to the social and healthcare sectors, there are strategic goals that concern the entire public sector administration. These are in line with the strategies for social and healthcare, but they emphasize cooperation and compatibility across the entire public sector, and also with the general population. Inherent in this is an aim to increase the ICT-skills of professionals, create efficiency in services, and where privacy issues allow to open the data for external use (Huovila, Aaltonen, Porrasmaa, Laaksonen, & Korhonen, 2015). Despite the efforts so far, data (especially in social services) is still collected in many ways. Municipalities and their social services have a large variety of ICT-­ systems and applications. One of the challenges this poses is that many publicly funded services are provided by small companies, and for them the requirement of investing in nationally harmonized ICT-systems and applications for client records may be very costly. Also, the high costs related to e-Welfare and e-Health may lead to a situation where small companies are not able to continue, and big multinational companies control the markets. This has already happened to a great extent in the area of care for older adults (Hoppania et  al., 2016). Besides developing unitary ways of collecting data, an essential factor is the exchange of information across services. For example, in social services there are many instances when having the patient data of the client would be beneficial. Incompatible ICT-systems may make this very difficult, and even when systems work together, if a client of social services does not allow access to their health data, then the data cannot be used. Therefore, there is not only a question of technology or incompatible systems, but times when conflicting aims and principles come into play. Especially, the need for client and patient integrity has to be balanced with the need for accurate and up-to-­ date information, and an assurance that user data is used only for the correct purposes. A firm legal framework is needed to steer the collection, storage, and use of client and patient data, for example, the Act on the Status and Rights of Patients (785/1992) or the Personal Data Act (523/1999). As part of the groundwork for the accurate collection and use of data, the stakeholders, operating environment, main information groups, data resources, and key information groups related to the processing of customer data in social welfare and healthcare have each been carefully described, with an aim to pave the way and create a nationwide information system entity for social welfare and healthcare (Huovila et al., 2015).

8.3  Experiences in e-Welfare and e-Health Two contextual examples of experiences in e-Welfare and e-Health can be used to give a picture of how the digitalization of social assistance (as e-Welfare) and the Kanta services (as e-Health) can reflect the digitalization of social and health services. Both systems are run by the Social Insurance Institution of Finland (Kela), and in the following sections I describe both examples and evaluate some of their associated experiences.

130

M. Zechner

8.3.1  Digitalization of Social Assistance In Finland, the system of social assistance (or income support) has been digitalized very recently, and at the same time that other changes have been made. Until the end of 2016, social assistance was entirely handled at a municipal level. Since the beginning of 2017 however, Kela has been tasked with managing the domain of basic social assistance. Basic social assistance is a benefit for those whose sustenance is not maintainable by working, self-employment, by receiving social security benefits, or by relying on their other income or assets. The basic social assistance is means-tested so that any income and assets are considered together with the expenses of all family members (Kela, 2017). Social assistance is a last-resort financial assistance for individuals and families covering some of the necessities of life. These include food, clothing, basic healthcare expenses, personal and household hygiene, local public transport, newspaper subscription, telephone and internet, hobbies and recreation, and other daily living expenses of individuals and their families. The three components of social assistance include basic social assistance, supplementary social assistance, and preventive social assistance (Kela, 2017). The supplementary social assistance covers special expenses (such as breaking of refrigerator) other than those met by basic social assistance and expenses arising from special needs or circumstances (e.g., long-term/serious illness or children’s leisure activities and hobbies). Preventive social assistance is used to advance the independent coping of an individual or family and to prevent social exclusion. It can be granted for instance to alleviate difficulties caused by over-indebtedness or a sudden deterioration of the financial situation (Social Assistance, 2017). Supplementary and preventive social assistance are still managed by the municipalities since people receiving these benefits may be in need of social work services that are not offered by Kela. When the administration of basic social assistance was shifted to Kela, the benefit system was digitalized at the same time. As a result, applications for social assistance can be completed online, but paper versions are also accepted. The upshot of this change caused massive queues and congestion for Kela, as they were unable to handle such a large number of new applications in the seven working day time period that is the legally mandated time in which to process them. Those working in Kela and handling the applications accused Kela of recruiting very few staff for managing the area of social assistance. While the municipalities had some 1500 persons working on social assistance, Kela had only 750 (Kelan henkilöstö huolissaan…, 2017). More staff were urgently recruited, and queues started to decrease (see Viitala, 2017). These events show that the expectations of savings that the digitalization of services would bring were, at least in the short term, exaggerated. The application queues are now managed better, but other challenges still persist. Kela has conducted a survey among their employees who work with social assistance. A questionnaire was sent to 700 members of staff in April 2017 and received a response rate of 63%. Only the preliminary results of the survey are available and these were presented in a seminar on 26th of April 2017 in Helsinki (2017). The questions presented in the seminar related to the strain that employees

8  Is Finland Connected for e-Health and e-Welfare?

131

working either as decision-makers or advisers on social assistance, experienced. Almost 80% of respondents felt a constant strain from having decisions delayed. Nearly 70% felt constant strain because of the complex legal framework and instructions for social assistance decisions. Approximately 65% felt constant strain due to incorrect decisions on social assistance. Over 60% felt constant strain due to a lack of time to perform their work properly, and finally, nearly half of the respondents felt strain due to dysfunctional ICT-systems (Heinonen, 2017). It seems that too many changes were undertaken at the same time. Employees needed to learn the principles and practices of a benefit that they had not handled before, and at the same time, Kela received approximately 200,000 new clients (Viitala, 2017) in a short period of time. Although some of the Kela employees had worked with the organization for some time, they had not been dealing with social assistance. Likewise, some of the new employees recruited to Kela had worked with social assistance in the municipalities, but were less familiar with the Kela ICT-­ systems. Kela has also been accused of not being willing to take on former municipal employees with experience in social assistance (see Muhonen, 2017). As another consideration, the ICT-systems used for social assistance are also new. Kelmu is the ICT-system for social assistance and eTotu is a part of Kelmu that allows Kela employees to inform municipalities of clients who may need supplementary or preventive social assistance, or social work services. The time needed for making social assistance decisions was evaluated to be 21–22 min per application. This proved to be too little, and a reason for this may be that the special features of social assistance and social assistance clients were not properly understood (Perustoimeentulotuen siirto Kelaan, 2017). Compared to most of the other benefits that Kela has so far been managing (for example child allowance or child home care allowance), social assistance is a complex benefit. The amount of factors and circumstances that influence a decision is vast, and clients for social assistance often face simultaneous and complex challenges in their lives. These may include, e.g., substance abuse, homelessness, and mental health issues. This makes social assistance a difficult benefit to manage, especially when the decision-makers are not social work professionals. Ultimately, the decisions on social assistance include a certain amount of discretion, which is less of a feature in the benefits that Kela has previously handled. The long time that is needed to handle each application probably relates to the fact that many clients are not able to benefit from an e-Welfare service. Instead, they need a personal assistance in order to make their application. This has resulted in long queues in Kela offices, and also in their telephone services. The Kela evaluation (Perustoimeentulotuen siirto Kelaan, 2017) revealed that at worst, the time needed to get a connection to the telephone service took 20 min. In the first few months of the service being launched, the answering rate for customer calls was particularly low, ranging from 30.1% to as low as 3.4%. Direct contact also has its issues, and when clients bring their applications by paper, documents (often with many attachments) need to be scanned so that they can be accessed by the ICTsystem. This work requires a lot of time although this may become less when clients

132

M. Zechner

are making return visits to the system or have already had some of their older documents scanned into the Kela ICT-system. These results tell many things about what needs to be considered when creating an e-Welfare system. Loading too many expectations onto one change process is unreasonable. In this case, not only was the benefit management system digitalized, but also the organization handling the benefit was changed and the majority of those working with social assistance had no prior experience of it. This meant not only was there inexperience in making decisions related to the area, but also a lack of experience in working with this specific client group. Furthermore, a change was also made so that the basic social assistance responsibility was transferred to Kela, while the supplementary and preventive social assistance responsibility remained with the municipalities. This has created a horde of challenges, and in some of the worse cases, clients have been sent back and forth between Kela and the municipalities. The information exchange between Kela and municipalities is currently insufficient (Näätänen, Londén, & Peltosalmi, 2017; Perustoimeentulotuen siirto Kelaan, 2017). This is especially crucial for clients who either get a negative decision on basic income assistance, or who need supplementary or preventive social assistance. These benefits are to a greater extent dependent on one another, which further complicates the issue. Many of the challenges that the digitalization of social assistance has faced can be solved with time. However, there has been an unacceptable amount of suffering, not only for those who work with social assistance, but especially those who have applied for social assistance and have been stuck in queues. Delays in paying rent, electricity, phone bills, or buying food and medication have caused unbearable problems for some individuals, and these are individuals who are already facing many challenges in their lives.

8.3.2  Kanta e-Health Service Kanta is the national data system service for healthcare, pharmacies, and citizens, and is gradually to be taken into use between 2016 and 2019. Kanta services include electronic prescription services, a Pharmaceutical Database, My Kanta pages, and a Patient Data Repository. My Kanta is a patient online service where individuals can browse their own health and medication records. In My Kanta, individuals have access to electronic prescriptions, treatment records, laboratory tests, X-ray examinations, and the health records of their dependents under 10 years of age. My Kanta also makes it possible to renew prescriptions, make a living will and organ donation testament, and consent to or refuse the disclosure of personal data. At least part of Kanta has existed for several years, so there are more studies on its user experiences than on the digitalization of social assistance. A national-level electronic survey on the usability of health information systems targeted at physicians of working age (N  =  14,411) in clinical work was conducted in 2014. Respondents came from public and private sectors, as well as from primary and

8  Is Finland Connected for e-Health and e-Welfare?

133

specialized care units. The questionnaire consisted of background questions, questions on system usability, on the degree of support for using the system, the experienced benefits, the most important development areas, and the best functionalities (Hyppönen et al., 2015). About 60% of physicians who responded to the survey found the electronic patient record and the technical functionality of the system to be satisfactory (good or fair). Better scores were given by those working in the private sector than those in the public sector, respondents over 55 years of age, and who had used the electronic patient record system for longer periods of time (Hyppönen, Lääveri, et al., 2015). Physicians who specialized in surgery, psychiatry, and internal medicine are generally the most critical towards electronic patient records and technical functionality (Vänskä et  al., 2014). About 40% of respondents from public hospitals and about 30% from healthcare centers indicated that the faulty functioning of the system had either caused or nearly caused a serious adverse event for the patient (Hyppönen, Lääveri, et al., 2015). In another study, fortunately, it was found that experiences of information disappearing from the IT system have been seen to decrease in both the public and private sectors (Kaipio et al., 2017). Nearly 70% of respondents found the Kanta services to be useful in facilitating cooperation between physicians within the same and across different organizations. However, less than 10% of private sector physicians and on average only 17% of public sector physicians agreed that health information exchange supports cross-­ organizational collaboration and information exchange. The availability of medication information was also poorly rated, receiving only 9–12% support across all sectors. Respondents from public primary care were most satisfied with the Kanta system (Hyppönen, Lääveri, et al., 2015). Winblad, Hämäläinen, and Reponen (2011) have previously noted that specialized healthcare seems to experience e-Health more positively, especially intra-organizational electronic services which are integrated into the electronic health record (e.g., digital radiology and laboratory services). At the same time, professionals working in primary healthcare have found inter-organizational data exchange and telemedicine to be especially positive developments. However, cooperation between patients and physicians does not receive very positive responses. Only about 20% of physicians in the private sector and 10% of physicians in the public sector felt that information systems eased their cooperation with patients. Assigning an active role to patients does not seem to be helpful in treatment either since only about 10% of all respondents agreed that “measurement results provided electronically by the patient (e.g. via the patient portal) help to improve the quality of care” (Hyppönen, Lääveri, et al., 2015). Cooperation between different services is essential. As an example, patients with mental health issues have a higher morbidity rate than other people, and this provides grounds for the integration of psychiatric and somatic healthcare services (De Hert et al., 2011). Studies have also shown that somatic care provided to patients with mental illnesses is less adequate than that provided to the population in general (Lumme, Pirkola, Manderbacka, & Keskimäki, 2016). Amenable mortality (which means premature deaths that could be avoided in the presence of effective and timely healthcare) has decreased in Finland. However, socio-economic inequities

134

M. Zechner

have been increasing and a greater inequity has been seen among deaths amenable to specialized healthcare interventions (Lumme, Sund, Leyland, & Keskimäki, 2012). Socio-economic inequalities are related to e-Health initiatives since those with lower income and educational levels are likely to have more difficulties in accessing and using ICT. For example, immigrants who have arrived as refugees or asylum seekers often have lower levels of income and education and may also have language difficulties (Malin & Gissler, 2006). Some other groups may benefit from e-Services. For example, people with disabilities may find e-Health and e-Welfare services more useful as they may help them to overcome certain physical barriers (Sachdeva, Tuikka, & Suomi, 2013). Generally, it is young people and those with high income and education levels who are likely to use new technologies to an increased degree and in a wider variety of ways (Räsänen & Koiranen, 2016). However, age as such does not necessarily create a gap in the use of e-Services, and it has been seen that older adults (50 and over) use digital services and gadgets if they find them useful in their everyday life and it suits their life situation (Wilska & Kuoppamäki, 2017).

8.4  Conclusions e-Welfare and e-Health seem to be suitable tools when trying to realize the policy ideas of active citizens that look after themselves by monitoring their health, preventing and curing their illnesses, and finding services and information to solve the social problems they face. However, it is not clear whether physicians are ready for such active patients as the questionnaire on the Kanta services tells that most physicians do not find them useful in patient cooperation (Hyppönen, Lääveri, et  al., 2015). Broad changes are taking place in the Finnish welfare state, moving towards an increasingly enabling welfare state, which instead of supporting, helping, and assisting enables individuals to support, help, and assist themselves and one another (see Gilbert, 2002; Saari, 2001). Against this backdrop, a degree of active citizenship is expected from individuals. e-Services tend to be built for capable and skilled users, be they professionals or clients and patients, and as such, there is a risk that those who are weakest and in most need will be left behind (Näätänen et al., 2017). e-Services bring many benefits, and timely and accessible client and patient data may make services more accurate, responsive, and adaptable to the needs of users. At best, e-Services can also enhance cooperation within and across organizations and sectors such as social and healthcare. However, this transition takes time and resources, and e-Services always seem to have unexpected challenges that are revealed only when the systems are taken into use. Drawing from the examples illustrated in this article, these include issues such as the missing information seen in the Kanta services, and the dysfunctional ICT-systems faced by those making decisions on social assistance. e-Welfare and e-Health are more than digitizing a business, and in the context of social and

8  Is Finland Connected for e-Health and e-Welfare?

135

health services, any loss of function or performance in supporting individuals may cause detriment or even an unacceptable loss of life. One of the strong incentives for digitalization relates to saving money. So far, digitalization has created costs since setting up the ICT-systems is expensive, and the preparatory work (e.g., making shared concepts for digital client and patient records) is onerous. Maintaining digitalized service systems also demands a commitment of resources, so it is possible that no monetary savings will be achieved. But, if future decision-making in social assistance is quicker and those in need of social work services gain access to them faster than now, then the positive social consequences may result in savings in the long run. If people learn to monitor their health, physicians learn to make use of the data that patients provide in e-Services and the client data is accurate, then the Finnish healthcare system may become more efficient and the future population may live healthier and longer lives. However, it is still not sure what will happen to the digital divide, or whether is it likely that the future generations, notwithstanding their economic or educational levels, will become digitally agile. e-Welfare and e-Health mean that services become increasingly standardized. Electronic patient records, referrals, client data, and social assistance applications use certain unified and standardized forms to collect information, and this means that application processes and services have become more homogenous across the country. Earlier, big differences were seen between municipalities in how they handled social assistance (Ihalainen, Hieta, & von Hertzen, 2014), and also the data that was collected and the format that was used. Standardization can be problematic, especially given that social assistance is a last-resort income benefit. Those needing social assistance have a very wide variety of life situations that need to be taken into consideration. Using electronic forms and standardized ways of handling these applications may mean that those with very complicated life situations may not manage to obtain social assistance. Also, those who find it difficult to use ICT may not be able to apply for social assistance although there is currently still the possibility to apply for it on paper. However, this has become increasingly difficult since there are fewer Kela offices than before, so distance may pose an obstacles for such applications. When e-Services are in place, a massive amount of data is generated, and there seems to be a shift away from an emphasis on technical infrastructure and towards an emphasis on governance and stakeholder involvement. Supporting business opportunities also remains an important strategic target (Hyppönen et  al., 2017). These issues are in line with the objectives of the Finnish Open Data Programme that aims to accelerate the opening of information resources free of charge, produce data in a machine-readable format, and provide transparent conditions of use to businesses, citizens, and society. The program aims at creating conditions for new business activity and innovation to strengthen democracy and civil society, to enhance administration, and to diversify the information resources available to education and research (Ministry of Finance, 2017). This seems to be the next step in e-Welfare and e-Health, and goes hand in hand with Finland’s ongoing social and healthcare reform where one of the aims is to increase marketization, competition,

136

M. Zechner

and free choice. However, it is yet to be seen whether this is possible without increasing the social inequalities that have been seen to emerge since the neoliberally inspired welfare state changes took place in Finland.

References Bertilsson, T. M., & Hjorth-Andersen, C. (2009). The Nordic welfare state. In G. T. Svendsen & G. L. H. Svendsen (Eds.), Handbook of social capital. The troika of sociology, political science and economics (pp. 212–277). Cheltenham: Edward Elgar. Cox, R. (2004). The path-dependency of an idea: Why Scandinavian welfare states remain distinct. Social Policy & Administration, 38(2), 204–219. De Hert, M., Cohen, D., Bobes, J., Cetkovich-Bakmas, M., Leucht, S., Ndetei, D.  M., et  al. (2011). Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 10(2), 138–151. Digitalisaatio terveyden ja hyvinvoinnin tukena. (2016). Sosiaali- ja terveysministeriön digitalisaatiolinjaukset 2025. Helsinki: Valtioneuvosto. Retrieved June 13, 2017, from http://julkaisut. valtioneuvosto.fi/bitstream/handle/10024/75526/JUL2016-5-hallinnonalan-ditalisaationlinjaukset-2025.pdf. Ervasti, H., Friberg, T., Hjerm, M., Kangas, O., & Ringdal, K. (2008). The Nordic model. In H. Ervasti, T. Friberg, M. Hjerm, & K. Ringdal (Eds.), Nordic social attitudes in a European perspective (pp. 1–21). Cheltenham: Edward Elgar. European Commission (2018) The Digital Economy and Society Index (DESI) 2018. Fact sheet. Retrieved January 31, 2019, from https://ec.europa.eu/digital-single-market/en/desi. Gilbert, N. (2002). Transformation of the welfare state. The silent surrender of public responsibility. Oxford: Oxford University Press. Hämäläinen, P., & Reponen, J. (2015). Finnish social and health care system and ICT-policies. In H. Hyppönen, P. Hämäläinen, & J. Reponen (Eds.), E-health and e-welfare of Finland. Check point 2015 (pp. 21–46). Helsinki: THL. Retrieved June 13, 2017, from https://www.julkari.fi/ bitstream/handle/10024/129709/URN_ISBN_978-952-302-563-9.pdf?sequence=1. Health, Social Services and Regional Government Reform. (2017). An internet site where the Finnish public sector reform is explained. Retrieved June 13, 2017, from http://alueuudistus. fi/en/frontpage. Heinonen, H. (2017). Kelan toimihenkilöiden näkemyksiä toimeentulotukityöstä. A Youtube recording from a Kela seminar titled Uusi toimeentulotukijärjestelmä ei ole vielä valmis–tutkimus kehittämisen tukena, 26 April 2017. Helsinki: Kela. Retrieved June 19, 2017, from https:// www.youtube.com/watch?v=08pYk7_Rk4E. Hoppania, H.-K., Karsio, O., Näre, L., Olakivi, A., Sointu, L., Vaittinen, T., et al. (2016). Hoivan arvoiset. Vaiva yhteiskunnan ytimessä. Tampere: Vastapaino. Huovila, M., Aaltonen, A., Porrasmaa, J., Laaksonen, M., & Korhonen, M. (2015). Sosiaalija terveydenhuollon valtakunnallinen kokonaisarkkitehtuuri. Periaatteet ja yhteiset linjaukset. Helsinki: THL.  Retrieved June 16, 2017, from https://www.julkari.fi/bitstream/ handle/10024/126970/URN_ISBN_978-952-302-531-8.pdf?sequence=1. Hyppönen, H., Hämäläinen, P., & Reponen, J. (Eds.). (2015). E-health and e-welfare of Finland. Check point 2015. Helsinki: THL.  Retrieved June 13, 2017, from https://www.julkari.fi/bitstream/handle/10024/129709/URN_ISBN_978-952-302-563-9.pdf?sequence=1. Hyppönen, H., Koch, S., Faxvaag, A., Gilstad, H., Nohr, C., Audur Hardardottir, G., Andreassen, H., Bertelsen, P., Kangas, M., Reponen, J., Villumsen, S., & Vimarlund, V. (2017). Nordic eHealth benchmarking. From piloting towards established practice. TemaNord 2017:528. Nordic council of Ministers. Retrieved June 13, 2017, from http://norden.diva-portal.org/ smash/get/diva2:1093162/FULLTEXT01.pdf.

8  Is Finland Connected for e-Health and e-Welfare?

137

Hyppönen, H., Lääveri, T., Kaipio, J., Vainiomäki, S., Vänskä, J., Reponen, J., et  al. (2015). Physicians’ use and usability of health information systems. In H. Hyppönen, P. Hämäläinen, & J.  Reponen (Eds.), E-health and e-welfare of Finland. Check point 2015. Helsinki: THL.  Retrieved June 13, 2017, from https://www.julkari.fi/bitstream/handle/10024/129709/ URN_ISBN_978-952-302-563-9.pdf?sequence=1. Ihalainen, P., Hieta, A., & von Hertzen, K. (2014). Laillisuustarkastuskertomus. Valtionosuus kunnille perustoimeentulotuen kustannuksiin. Valtiontalouden tarkastusviraston tarkastuskertomukset 12/2014. Helsinki: Valtiovarainministeriö. Kaipio, J., Lääveri, T., Hyppönen, H., Kushniruk, A., Vainiomäki, S., Reponen, J., et al. (2017). Usability problems do not heal by themselves: National survey on physicians’ experiences with EHRs in Finland. Medical Informatics, 97, 266–281. https://doi.org/10.1016/j. ijmedinf.2016.10.010 Kela. (2017). Kela internet pages on Social assistance. Retrieved June 15, 2017, from http://www. kela.fi/web/en/social-assistance. Kelan henkilöstö huolissaan perustoimeentulotuen toimeenpanosta. (2017). A statement given by the Kela professional branch of PARDIA, The federation of salaried employees 23.2.2017. Retrieved June 19, 2017, from https://www.pardia.fi/kelantoimihenkilot/?x1796127=11825262. Laaksonen, M., & Ailio, E. (2011). Terminologisen sanastotyön ja luokitustyön yhdistäminen. In K.  Häyrinen (Ed.), Sosiaali- ja terveydenhuollon tietojenkäsittelyn tutkimuspäivät (Tutkimuspaperit 2011). Helsinki: THL.  Retrieved June 16, 2017, from https://www.julkari. fi/bitstream/handle/10024/80252/b0105265-570a-4f89-8c98-f7b3da930d51.pdf?sequence=1. Lumme, S., Pirkola, S., Manderbacka, K., & Keskimäki, I. (2016). Excess mortality in patients with severe mental disorders in 1996-2010 in Finland. PLOS One, 11(3), e0152223. https://doi. org/10.1371/journal.pone.0152223 Lumme, S., Sund, R., Leyland, A.  H., & Keskimäki, I. (2012). Socioeconomic equity in amenable mortality in Finland 1992-2008. Social Science & Medicine, 75(5), 905–913. https://doi. org/10.1016/j.socscimed.2012.04.007 Malin, M., & Gissler, M. (2006). Maahanmuuttajien terveys- ja sosiaalipalveluiden saatavuus, laatu ja käyttöoikeudenmukaisuuden näkökulmasta. In J. Teperi, L. Vuorenkoski, K. Manderbacka, E.  Ollila, & I.  Keskimäki (Eds.), Riittävät palvelut jokaiselle. Näkökulmia yhdenvertaisuuteen sosiaali- ja terveydenhuollossa (pp.  115–133). Helsinki: Stakes. Retrieved June 25, 2017, from https://www.julkari.fi/bitstream/handle/10024/76061/M233%20-%20VERKKO. pdf?sequence=1#page=110. Matveinen, P., & Knape, N. (2016). Terveydenhuollon menot ja rahoitus 2014. Helsinki: THL.  Retrieved June 15, 2017, from https://www.julkari.fi/bitstream/handle/10024/130783/ Tr13_16_FI_SV_EN.pdf?sequence=4. Meagher, G., & Szebehely, M. (Eds.). (2013). Marketisation in Nordic eldercare: a research report on legislation, oversight, extent and consequences. Stockholm: Stockholm University Press. Ministry of Finance. (2017). Onward from the Finnish Open Data Programme. Helsinki: Ministry of Finance. Retrieved June 25, 2017, from http://vm.fi/en/open-data-programme. Muhonen, T. (2017). Näin Kela-kriisi alkoi: Kunnat tarjosivat työntekijöitään – “Kela ei halunnut heitä”. Newspaper article in Talouselämä 17 March 2017. Retrieved June 19, 2017, from http:// www.is.fi/taloussanomat/art-2000005132006.html. Näätänen, A.-M., Londén, P., & Peltosalmi, J.  (2017). Sosiaalibarometri 2017. Helsinki: SOSTE.  Retrieved June 15, 2017, from https://www.soste.fi/media/soste_sosiaalibarometri_2017.pdf. Perustoimeentulotuen siirto Kelaan. (2017). Kelan sisäinen arviointi 2017. Helsinki: Kela. Retrieved June 19, 2017, from http://www.kela.fi/documents/10180/3571044/toturaportti0806. pdf/06f4fd6b-50de-4302-b6ea-ac5c2adb0ae9. Räsänen, P., & Koiranen, I. (2016). Changing patterns of ICT use in Finland – The senior citizens’ perpective. In J. Zhou & G. Salvendy (Eds.), Human aspects of IT for the aged population. Design for aging. Second International Conference, ITAP 2016, Toronto, ON, Canada, July 17–22, 2016, Proceedings, Part I, 226−237. Saari, J. (2001). Reformismi. Sosiaalipolitiikan perusteet 2000luvun alussa. Helsinki: Gaudeamus.

138

M. Zechner

Saari, J. (2017). Oleskeluyhteiskunta. In J. Saari (Ed.), Sosiaaliturvariippuvuus. Sosiaalipummit oleskeluyhteiskunnassa? (pp.  13–35). Tampere: Tampere University Press. Retrieved June 15, 2017, from http://tampub.uta.fi/bitstream/handle/10024/100775/Saari_Sosiaaliturvariippuvuus. pdf?sequence=1. Sachdeva, N., Tuikka, A-M., & Suomi, R. (2013). Digital disability in information society: The case of impairments. In T. Ward Bynum, W. Fleishman, A. Gerdes, G. Møldrup Nielsen, & S. Rogerson (Eds.), Proceedings of the Thirteenth International conference. The possibilities of ethical ICT. ETHICOMP 2013. University of Southern Denmark, Kolding Campus, Denmark, June 12–14, 2013. Retrieved June 24, 2017, from https://www.researchgate.net/profile/Simon_ Rogerson/publication/260298598_ETHICOMP_2013_Conference_Proceedings_The_possibilities_of_ethical_ICT/links/56b71c3d08aebbde1a7b163b.pdf#page=414. Social Assistance. (2017). Ministry of Social Affairs and Health internet page explaining the Finnish social welfare. Retrieved June 19, 2017, from http://stm.fi/en/income-security/ social-assistance. Sosiaalialan tiedonhallinnan sanasto. (2017). Palveluihin, palveluprosesseihin ja asiakastietoihin liittyviä käsitteitä. Versio 3.0. Helsinki: THL. Retrieved June 13, 2017, from https:// www.thl.fi/documents/920442/2920708/sosiaalialan_tiedonhallinnan_sanasto_versio_3_0. pdf/06ef0be0-2503-48ee-972a-1ca7dd7becfe. Sosiaaliturvan menot ja rahoitus 2015. (2017). Helsinki: THL.  Retrieved June 15, 2017, from https://www.julkari.fi/bitstream/handle/10024/132142/Tr_07_17_kokonaisraportti. pdf?sequence=4. Tieto hyvinvoinnin ja uudistuvien palvelujen tukena  - Sote-tieto hyötykäyttöön -strategia 2020. (2015). Helsinki: Ministry of Social Affairs and Health. Retrieved June 13, 2017, from http:// julkaisut.valtioneuvosto.fi/handle/10024/70321. Van Aerschot, L., & Zechner, M. (2014). Is there a Nordic model of elder care?  - Similarities and differences between Denmark, Finland, Norway and Sweden. In M.  Pietrzykowski & T. Toikko (Eds.), Sustainable welfare in a regional context (pp. 116–138). Seinäjoki: Seinäjoki University of Applied Sciences. Retrieved June 13, 2017, from https://www.theseus.fi/bitstream/handle/10024/85076/B83_Sustainable%20welfare%20in%20a%20regional%20context.pdf?sequence=1. Vänskä, J., Vainiomäki, S., Kaipio, J., Hyppönen, H., Reponen, J., & Lääveri, T. (2014). Potilastietojärjestelmät lääkärin työvälineenä 2014: käyttäjäkokemuksissa ei merkittäviä muutoksia. Suomen Lääkärilehti, 49(69), 3351–3358. Viitala, S. (2017). Uutissuomalainen: Kela on saamassa toimeentulotuen jonot kuriin. Newspaper article in Turun Sanomat 18 April 2017. Retrieved June 19, 2017, from http://www.ts.fi/uutiset/ kotimaa/3478453/Uutissuomalainen+Kela+on+saamassa+toimeentulotuen+jonot+kuriin. Wilska, T-A., & Kuoppamäki, S-A. (2017). Yhteenveto ja johtopäätökset. In T-A Wilska & S-A.  Kuoppamäki (Eds.), Varttuneet kuluttajat, digitalisoituva arki ja kulutusympäristöjen muutos. Digi 50+ -hankkeen loppuraportti. 209/2017. Jyväskylä: Jyväskylän yliopiston kauppakorkeakoulu. Retrieved June 24, 2017, from https://jyx.jyu.fi/dspace/bitstream/handle/123456789/54393/978-951-39-7101-4.pdf?sequence=1. Winblad, I., Hämäläinen, P., & Reponen, J. (2011). What is found positive in healthcare information and communication technology implementation?—The results of a nationwide survey in Finland. Telemedicine and e-Health, 17(2), 118–123. https://doi.org/10.1089/tmj.2010.0138

Part IV

China

Chapter 9

Social Construction, System Defects, and System Quality of a Welfare Policy and Regulation Framework for the Elderly of China Jitong Liu and Yu Liu

9.1  D  evelopment Stages and Characteristics of the Welfare Policy Periods for the Elderly of China The historical development of welfare policies for the elderly in China can be divided into four time periods between the years 1949 and 2015. The year 2015 will go down in history as the first year of modern welfare for the elderly in China, symbolizing the entrance into the framework construction of modern welfare policies for the elderly in China and thus a brand new historical development stage. We divided the development of socialistic welfare policies for the elderly of China into four basic time periods based on the analytical aspects of macroscopic historical background, the main social problems, nationhood and the nation’s role, the living conditions of the elderly, related governmental policies and regulations for the elderly, the main influential factors of governmental campaigns, and the typical characteristics of the problems and welfare policies for the elderly. The first period is from 1949 to 1981, which can be characterized by socialistic collectivism and a traditional culture of respecting the old and cherishing the young. Although the elderly had not yet constituted a social problem in this time period, there were no clear policies from the government. The period from 1982 to 1999 is social concern and the formative time of the elderly welfare policy. During that time,the most social feature is all society began to concern the elderly and provisions for the elderly which became policy issues.  The elderly problems first became social problems,but the goverment had no explicit policy. In the period from 2000 to 2014, the basic formation of welfare policies, regulation frameworks, and service system frameworks for the elderly of China occurred. During this time period, the problems of and provisions for the elderly first became J. Liu · Y. Liu (*) Department of Health Policy and Management, School of Public Health, Peking University, Haidian District, Beijing, P.R.China e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_9

141

142

J. Liu and Y. Liu

a priority issue in the social policy agenda of China. A theme of the time was how to establish a modern welfare system for the elderly of China. The government recognized that the problems of the elderly were severe social problems and actively responded to this social concern; as a result, the welfare policy and service system frameworks for the elderly in China came into being. The year 2014 was not only the first year for China to deepen the reform, but it was also the first year for China to build the rule of law and a modern welfare system for the elderly in China; this marked the beginning of the construction of modern welfare system and service system frameworks for the elderly in China, thus setting a milestone. The problems of the elderly are major, urgent, and severe social and political problems, as well as being substantial problems in the construction of a modern welfare system for the elderly. In the more than 60 years since the founding of the People Republic of China in 1949, the historical development of national policies for the elderly progression from nonexistent to robust, from small to large, from part to whole, from personal troubles to social problems, from social concerns to policy topics, from marginal to mainstream, from welfare policies to a welfare system construction—all of which clearly reflect the changing track of Chinese society and social welfare modernization. The founding of the People Republic of China on October 1, 1949, marked the historical beginning of the socialistic modernization construction of China. During the period from 1949 to 1978, when Chinese government was implementing the policies of reform and “opening up,” the background of the macroscopic social system in China was the socialist planned economy system; all production, living, consumption, and investment activities of the Chinese society were included in a national annual plan and a 5-year plan. At that time, there was no such concept of “social problems” because there are no social problems in a socialist society; social problems are a unique phenomenon of a capitalist society. Major social problems are presented within the concept of “difficulty and contradiction,” such as the difficult living conditions of workers (Ministry of Labor and Social Security, The Department of Insurance and Welfare, 1989). The state has absolute authority and plays a parental role by administering and controlling all areas of life—social, economic, and cultural—in a unified manner. In the dualistic urban and rural social welfare system of that time, the main service targets of social welfare were limited to a few urban residents. Because the economic and social development levels were low at that time, the main services of social welfare included welfare service, social insurance, social relief, and allowances. At that time, the material living conditions of the elderly were not very affluent, but the spiritual life of the elderly was characterized by optimism and contentment, and the overall living conditions were good. At that time, the central government mainly simulated the Soviet mode by formulating and issuing a series of pensions for the elderly, as well as medical, industrial injury, and birth insurance policies. The main motivation of the government was to carry out welfare services, social insurance, and social assistance to “embody the superiority of the socialist system.” Overall, the process of development in China was affected by many factors, such as the international cold war environment between the East and the West after World

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

143

War II, socialist ideology, a planned economic system, a low economic development level, the long-term chaos caused by war since the Revolution of 1911, and historical problems left over by warlordism, among others. Since late 1950s, political movements emerged in an endless stream, especially in the decade of disaster known as the “Cultural Revolution”. At that time, the elderly were not a main problem of concern in society, and the overall social effect of insurance and welfare policies for urban residents was good (Yan, 1987). The typical viewpoint of the era of this planned economic system was “there was no problem of the aged.” However, the most typical characteristics of the times include the nation taking charge of social insurance and welfare system construction, elderly is no problems, the presence of insurance, and an urban and rural dualistic welfare system, with social insurance coming first and social assistance second. The Third Plenary Session of the 11th CPC Central Committee in 1978 marked the beginning of the era of reform and opening up. The opening-up and economic restructuring policies implemented by the nation became not only distinctive characteristics of a new era, but they also constituted the principal macroscopic social background and symbolized China’s entrance into a brand-new era. The reform policy of China began with rural reform. In 1984, the central government issued a decision to implement an “urban economic system reform.” State-owned enterprises widely practiced three institutional reforms in labor employment, wages, and social insurance, but staff employment and living problems emerged (Zhou, 1987). After the delivery of the South Inspection Speech by Deng Xiaoping in 1991, the enterprises widely reduced staff for greater efficiency and to build up the socialist market economy system. Because of employment reform measures, urban  poverty problems emerged and the guaranteed minimum living standard for enterprise staff became a major social problem (Duojicairang, 2001). Since the reform and opening up (especially since 1991), the economic market and power of the market economy have increased. In addition, social organizations were burgeoning and developing, and the leading role of the nation had not been weakened by a tripartite confrontation between the nation, market, and civil society. The market economy and non-governmental organizations became two wings of the nation, and the capabilities of macroscopic management and finance channeling of the country significantly increased (Wang & Hu, 1993). Since the reform and opening up, social mobility between urban and rural areas became more frequent. Many migrant workers traveled to towns to seek jobs or conduct business. However, the dualistic welfare system remained the same; the targets for social insurance, social assistance, and worker welfare services were still limited to urban workers and union members; and the target scope remained unchanged. At the same time, some new services were added for the elderly, mainly the urban and rural community services arising in the 1980s, financial aid to workers having difficulty, employment assistance, poverty relief service, and a local pilot program of social old-age pension insurance in rural areas that was implemented in the 1990s (Cui, 1994). Since the reform and opening up, the problems of providing for the elderly and living conditions in urban and rural areas had become social issues of concern for the whole society. In 1982, the “problem of the elderly” first

144

J. Liu and Y. Liu

appeared in public documents and became an independent policy issue. In March 1982, the China Committee of World Assembly on Aging was founded. In July 1982, the Chinese government sent representatives to attend the World Assembly on Aging in Vienna. On October 20, 1982, the China Committee of World Assembly on Aging was renamed to the China National Committee on Aging. Founded in October 1999, the National Working Commission on Aging was a deliberative and coordinating organization for the State Council to take charge of the work on aging nationwide. In August 2005, the offices of the National Working Commission on Aging and China Aging Association began to handle official business together; this not only reflected the international motivation for China to develop policies for the elderly, but it also marked an active administrative response of the nation to the problems of the elderly (www.cncaprc.gov.cn). Furthermore, it suggested that, in a social environment of reform and opening up, the influential factors of welfare policies for the elderly were gradually becoming multi-dimensional, structural, and international. In August 1996, the Law of the People’s Republic of China on the Protection of the Rights and Interests of the Elderly was passed during the 21st meeting of the Eighth Standing Committee of National People’s Congress, marking social recognition of working for the elderly by the China National Committee on Aging and the entrance of elderly issues into an era of welfare policies and rule of law. Overall, since the reform and opening up, the problems of the elderly in China became a national policy issue, and the welfare policy and service system frameworks for the elderly of China were preliminarily established in legal form. The year 2000 marked not only the start of the twenty-first century, but also a major turning point in the development of Chinese modern history. After the development of a market economic system and radical reform of the management system of state-owned enterprises in 1990s, issues of social development emerged, focusing on improving people’s livelihood and building a harmonious socialist society (The CPC Central Committee, 2006). In 1999, the population over 60 years old in China reached 126 million, including 86 million who were over 65  years old, accounting for 10% and 7% of the total population, respectively. According to widely accepted standards across the world, the population structure of China began to enter the stage of an “aging society.” At the same time, prominent social problems emerged and needed to be solved, including urban and rural poverty, income gaps, unfair social distribution, limited job opportunities, guaranteed subsistence allowances, and the establishment of “social security” system, mainly including social insurance, social relief, and survivor benefits. Since 2000, state financial resources, national economic strength, national overall strength, and the national ability for macroeconomic regulation and control have been increasing and getting stronger every day. The administrative powers have extensively taken control of the market economic system operations and construction of civil society and social organizations, and the government became powerful enough to exercise state power. Since 1990, comprehensive social insurance has been provided for migrant workers in Guangdong, Shanghai, Shenzhen, and Chengdu. Moreover, the old-age insurance system for new farmers was implemented throughout the country in 2012; therefore, the old-age insurance service

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

145

targets basically covered the entire population. In addition to the guarantee of old-­ age security pension, there emerged diverse service guarantees, such as re-­ employment, medicine, education, culture, and entertainment (Hu, 2009). Overall, the living conditions of healthy old people were generally good, but that of semi-­ disabled, completely disabled, solitary, and very old people were worrying (Mu, 2015). Since 2000, the number of old-age related problems and welfare policies for the elderly has been increasing drastically, which is largely due to the National Office on Ageing. Approved by the Party Central Committee and the State Council in October 1999, the National Committee on Ageing was founded in Beijing, with an office in the Ministry of Civil Affairs and daily work that was undertaken by the China Ageing Association. Thus, a new mode of the welfare administrative management system, as well as policies and regulations for the elderly on a national level, were founded. What is more important is that, since 2000, a major historical transition occurred in public policy in China; the social pressure from a single economic policy and social policy, internal factors of social development in China, and social structures have become increasingly prominent (Wang, 2007). The concept of social policy reappeared in the theoretical academic community of China, which clarified the social structural transition and endogenous motivation of policy in China. Therefore, many factors were highly correlated, such as international and domestic factors, system factors, and mechanical factors. In the 1990s, many scholars began to advocate for the problems of the aging population, with society worrying that “the wolf is coming.” Since 2000, a major transition occurred in that the rapid and explicit phenomenon of aging people suffering from illness became a severe social reality that must be addressed. The central government issued a series of policies and regulations on the problems of the elderly, but the social effect achieved was not obvious. The actual problems became more severe every day, but an effective system construction to respond to them was lacking. Thus, a high-quality system construction became the goal of the times. The year 2014 was not only the first year for China to initiate comprehensive reform, but also the first year for China to build a country under the rule of law and the first year for China to build a welfare country. This time has been referred to as the great rejuvenation of the Chinese nation and China’s dream, which is to build a moderately prosperous and happy society in a comprehensive way (The CPC Central Committee, 2014). More than thirty years had passed since the reform and opening up. Especially since the implementation of the market economic system construction, radical reform of state-owned enterprises in 1990s, and extensive intervention of the state in the competitive market economy, many political, economic, social, and cultural problems appeared and were becoming increasingly severe. The problems of social welfare and quality of life had an intrinsic social nature; they were given more political, economic, cultural, and global significance (Sun, 1994). In 2010, the old-age pension insurance in China was extended from urban workers and residents to hundreds of millions rural residents, thus covering the entire population. In 2014, the nationwide offspring fetching pension and attendance allowance system was firstly carried out in Nanjing City, which laid the

146

J. Liu and Y. Liu

f­ oundation for home-based care for the aged (The Nanjing Government, 2014). In 2015, the Regulations on the Provision of Home-Based Care for the Aged of Beijing Municipality were passed in the 14th National People’s Congress in Beijing, which defined the government as the subject of liabilities for provisions for the elderly (The People’s Congress of Beijing Municipal, 2015). Since 2000, nationwide care and nursing for the elderly had been actively explored in Qingdao, Shandong province, and long-term care insurance system for disabled elderly people was initiated (Ding, 2015). Thus, since 2015, services for the elderly have been increasing, indicating that we have entered an era of modern welfare system construction with health and welfare integration for the elderly. According to six previous policy targets in China, the ideal living mode for the elderly should be positive and healthy, with dignified aging. Since the reform and opening up, the phenomena of the aging of the population, miniaturization of families, and elderly parents living on their own were accompanied by “3 absences” and “5 guarantees” (“3 absences” means no income, no labor ability, no guardians and “5 guarantees” means eating, cloths, housing, medical care,and burying). The living difficulties of very old people, disabled elderly, and low-income elderly were major problems; thus, welfare policies for the elderly became a primary objective for welfare reform in China (Cheng, 2010). It was also important to construct a modern welfare system and service system for the elderly according to the historical social and cultural traditions of China. In general, political modernization, economic modernization, social modernization, and cultural modernization are the main driving forces in the development of welfare policies for the elderly (He, 2010). At the same time, the political philosophy , state responsibility, welfare legitimacy, urgent actual needs, and social pressure will be the main influential factors (Shao & Bi, 2014). Overall, prudent and optimistic attitudes have been taken toward the quality of welfare system construction and the influence of welfare policies to the society in the future. In view of the two 100-year development goals—the goal of 100 years from the founding of the Chinese Communist Party and the goal of 100 years from the founding of the People’s Republic of China—we believe that the theme for social development in China from 2015 to 2050 is to become a welfare state and a welfare society because China has entered into an era of modern social policies, social welfare, and social legislation (Liu, 2011a) (Table 9.1).

9.2  W  elfare Policy and Regulation Framework and System Characteristics for the Elderly of China The framework of the welfare policy and regulation system for the elderly has rich meanings and diverse denotations. In this article, the term “welfare policy and regulation system for the elderly” mainly refers to the generic terms of related laws and regulations issued by the central government. According to the regulations of the Legislation of the People’s Republic of China, the legal system of China includes

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

147

Table 9.1  Historical development stages and characteristics of the time periods of welfare policies and regulations for the elderly of China (1949–2015) Analytic level Microscopic social background Main social problems

1949–1981 Planned economic system Living difficulties of workers

Nationhood and High centralization nation role Main service target Main service contents

Limited to urban residents Welfare, insurance, relief and allowances Good overall Living conditions of the conditions elderly Welfare policies Provisions for the of the elderly elderly, medical, occupational injuries, and birth Superiority of Motivation of socialism government policies Main influential History, system, factors and concept Social No feelings on the influential effect whole Typical characteristics of the times

Non-problem, presence of insurance

1982–1999 Policy of reform and opening up Minimum standards of living State authority and role

2000–2014 Harmonious society construction Social security system

Domestic and overseas factors Multiple structures, international Positive response from society Politics, law, and framework

Intrinsic and system pressure

2015– Chinese version of a welfare country Social welfare system

Typical power state Responsible service government Urban workers Pension insurance Pension insurance for all citizens for all citizens Additional Comprehensive Health and social services social services welfare integration Positive healthy Issues of aging times with welfare social concern diseases and sufferings Welfare for the Policies and First become Chinese elderly regulations at a independent national level issues Modernization of social structure

System and Political and mechanism factors social pressure Aging with explicit diseases and sufferings  Major problem, no system

Maintain a prudent and optimistic attitude Welfare state and society

Sources: the table is formulated by the authors.

eight types of laws, regulations, and rules that reflect the legal system and legislative procedures, including laws, law interpretations, administrative laws, department regulations of the State Council, local regulations, local government rules, autonomous regulations, and specific regulations. In addition, there are also related policies and regulations issued and implemented by the Chinese Communist Party and Central Military Commission . Generally, the policy documents jointly issued by the Central Committee of the Communist Party of China and the State Council have the highest authority, reflecting not only a political system with high integration of the party and the state, but also the will of the state (Liu, 2011b). More importantly, according to the prescriptions of the constitution, the administrative organizational

148

J. Liu and Y. Liu

structure of the government of China is composed of five levels—namely, the central government, provincial government, city and county governments, district governments, and town governments; the governments of all levels, especially provincial and sub-provincial governments , formulate large quantities of policies and regulations according to local requirements (Office of the Secretary General of the State Council, General Division of the Office of the Central Compilation Committee, 2009). Therefore, this study mainly focused on the central government—that is, the welfare policies and regulations for the elderly and related regulations formulated by the Central Committee of the Communist Party of China, State Council, National People’s Congress, Central Military Commission, and all functionary ministries of the State Council. The study observed and analyzed developments and change trends in the welfare policy and regulation system for the elderly in China, summarized the basic characteristics and Chinese characteristics of the framework of the welfare policy and regulation system for the elderly in China (which provides the related system background information for subsequent content analysis and deep analysis of policies and regulations), and outlined the framework of the policy and regulation system of China. The analytical framework of the central government’s welfare policy and regulation system and related policies and regulations for the elderly was drafted by the author. Three main sources were used to determine the welfare policies and regulations for the elderly: (1) the official website of the Department of Social Welfare and Philanthropy Promotion, Ministry of Civil Affairs; (2) the official website of the Office of the National Committee on Ageing; (3) other sources sought out and confirmed by the author according to the history of welfare policy construction for the elderly. Firstly, there is still room for improvement in the quality of government websites. The data sets on the two official websites were not necessarily the same, so the information from the two websites was cross-checked to provide an integral whole; however, they generally reflect the framework of a welfare policy and regulation system for the elderly. Secondly, the earliest data for the issuance of policies and regulations on the website of the Ministry of Civil Affairs was 2005, but the issuance of policies and regulations of the central government and local governments by the National Office on Ageing date back to 2007. This typically reflects the overall quality of policy and regulation construction in China, especially from the aspects of government information publicity, government work transparency, and the historic significance, systematicness, completeness, and authority of national policies and regulations. Therefore, it is an arduous task and the road is long to improve science of major social policies of the central government and the democratic decision-making level (Li, 2015). Thirdly, and most importantly, this study selected three levels from which to analyze policies and regulations—namely, issuance time, issuance institution, and titles of policies and regulations—to try to outline a complete picture of the welfare policies and regulations for the elderly and related policies and regulations of China. As for the issuance time, the study observed the historical changing sequence of welfare policies and regulations for the elderly to reflect development time sequence. As for issuance institutions, the

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

149

study mainly used policy and regulation formulating units as the subject to evaluate the identity and position of the policy and regulation formulating units to define policy and regulation authority. As for the titles of policies and regulations, the study mainly analyzed policy and regulation content, with a main objective to reflect the response of the government to the main welfare problems of the elderly at that time. In brief, the historical development status of welfare policies and regulations for the elderly of China typically reflected the framework and systematic characteristics of the welfare policy system (Table 9.2). Since the release of the first Law of the People’s Republic of China on the Protection of Rights and Interests of the Elderly in 1996, related welfare policies and regulations for the elderly of the central government typically reflected the framework, scope, contents, and system characteristics of the welfare policy and regulation system for the elderly of China. This is the basic mode to observe and understand state social policy and social legislation, the orientation, position and role of government functions, and optimal cases and the perspective of government operation. Firstly, from the perspective of welfare policies and regulations for the elderly and related policies and regulations of China, the welfare policies and regulations for the elderly of China are in a rapid development stage; however, a clear and definite overall framework for welfare policies and regulations for the elderly of the central government is lacking. The Central Committee of the Communist Party of China, State Council, National People’s Congress, Central Military Commission, and all functionary ministries of the State Council each administers in its own way and formulates policies independently; this is evidenced by the lack of an overall framework of modern welfare policies and regulations for the elderly of China or complete strategic planning and design of a comprehensive welfare service system. Secondly, the central government lacks clear strategic planning and design of modern welfare policies and regulations for the elderly. However, the development trends and overall development direction of the welfare system construction for the elderly of China are very clear and distinct, which indicates the development direction for the welfare system for the elderly in China: (1) welfare policies for the elderly are changing from being limited to urban workers to covering all citizens, and the framework of an old-age pension insurance system for all citizens has taken shape; (2) welfare for the elderly is changing from urban-rural dualism to urban-­ rural integration, and the target of building a basic pension insurance system with urban-rural integration is clear; (3) from the perspective of time for the formulation of related welfare policies and regulations for the elderly by the central government (e.g., the years 2000 and 2010), there was only one important law before 2000: the People’s Republic of China on the Protection of the Rights and Interests of the Elderly (accounting for 1/37 of the total). During the period from 2000 to 2009, there were six important policies and regulations nationwide, accounting for approximately 16% of the total important policies and regulations (37). Since 2010, and especially since 2012, it can be clearly seen that the number of questions on policies and regulations for the elderly has been on a sharp increase, reflecting the

150

J. Liu and Y. Liu

Table 9.2  Developments and changes in the main welfare problems for the elderly and related policies and regulations (1996–2015) Time of issuance 1996.8

Issuance institution Titles of policies and regulations The 21st meeting of the Eighth Standing Law of the People’s Republic of China Committee of National People’s Congress on the Protection of the Rights and Interests of the Elderly Advices on Speeding up Realization 2000.2 Ministry of Civil Affairs, State Development Planning Commission and of Socialization of Social Welfare State Economic and Trade Commission, etc. 2000.7 The Central Committee of the Communist Decisions of the Central Committee of Party of China, the State Council the Communist Party of China and the State Council to Strengthen the Work on Aging Advices on Speeding up the 2006.2.9 10 ministries and commissions, such as the Office of the National Committee on Development of Old-age Service Industry Ageing and National Development and Reform Commission, etc. 2007.3 The State Council Some Advices on Speeding up the Development of Service Industry Advice on Comprehensively 2008.2. 10 ministries and commissions, such as the Office of the National Committee on Promoting Home-based Care for the Elderly Ageing and National Development and Reform Commission, etc. 2009.6.4 General Office of the Ministry of Civil Notice on Circulation of Related Affairs Policies on Establishing Allowance System for Very Old People in Ningxia 2010.8.31 Central Military Commission Regulation for the Work for Cadre Sanatorium of the Chinese People’s Liberation Army 2010.10.28 The 17th meeting of the 11th Standing The Social Insurance Law of the Committee of National People’s Congress People’s Republic of China 2011.9.17 The State Council Notice on Printing the Development of Aging Undertakings of “12th Five-Year Plan” 2012.7 Ministry of Civil Affairs Advice on Encouraging and Channeling Private Capital into Service for the Elderly Advice on Further Strengthening 2012.9.13 16 ministries and commissions of the Old-Age Cultural Construction Organization Department of the Central Committee of the CPC and the Propaganda Department of the Central Committee of the CPC and the Ministry of Civil Affairs, etc. (continued)

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

151

Table 9.2 (continued) Time of issuance 2012.10

Issuance institution Ministry of Civil Affairs

Titles of policies and regulations Advice on Carrying out “Promotion year for Social Old-age Service System Construction” Activity and Initiating “Respecting, Care for and Providing Aid to the Elderly” 2012.12 The 30th meeting of the 11th Standing Law of the People’s Republic of China Committee of National People’s Congress on the Protection of the Rights and Interests of the Elderly 2013.4 Ministry of Finance and Ministry of Civil Rural Welfare Home Project Affairs Supported by Public Welfare Fund from Lottery of the Central Government 2013.6.28 The Ministry of Civil Affairs Measures for Permit of Establishment of Institutional Care for the Elderly 2013.6.28 The Ministry of Civil Affairs Management Measures of Institutional Care for the Elderly 2013.9.6 The State Council Some Advices on Accelerating Old-Age Care Service Industry 2013.9.26 General Office of the State Council (Guo Guiding Principles of Purchase of Ban Fa [2013] No. 96) Service from Social Force by the Government 2013.9.28 The State Council Some Advices on Promoting Development of Healthy Service Industry Advices on Further strengthening 2013.12.30 24 ministries and commissions, such as Office of National Working Commission Special Treatment to the Elderly on Ageing and Supreme People’s Court Guiding Advice on Strengthening 2014.2.10 6 ministries and commissions, such as Standardized Work of Old-age Service Ministry of Civil Affairs, National Standardization Committee and Ministry of Commerce Notice on Strengthening the Planning 2014.2.13 Ministry of Housing and Urban-Rural and Construction of Old-age Service Development, Ministry of Land and Facilities Resources, Ministry of Civil Affairs and National Working Commission on Ageing  2014.2.21 The State Council Advice on Construction of Unified Basic Old-Age Pension Insurance System for Urban-Rural Residents 2014.2.24 Ministry of Human Resources and Social Interim Measures on Convergence of Security, Ministry of Finance Urban-Rural Old-Age Pension Insurance System 2014.2.28 Ministry of Civil Affairs, China Insurance Guiding Advices on Promoting Institutional Old-Age Liability Regulatory Commission and National Insurance Working Commission on Ageing  2014.4.17 Ministry of Land and Resources Guiding Advice on Land-Use for Old-Age Service Facilities (continued)

152

J. Liu and Y. Liu

Table 9.2 (continued) Time of issuance 2014.5.28

2014.6.17

Issuance institution Ministry of Civil Affairs, Ministry of Land and Resources, Ministry of Finance and Ministry of Housing and Urban-Rural Development China Insurance Regulatory Commission

2014.7.8

Ministry of Housing and Urban-Rural Development, Ministry of Civil Affairs, Ministry of Finance, Chinese Disabled Person Federation and National Working Commission on Ageing  2014.8.26 Ministry of Finance, National Development and Reform Commission, Ministry of Civil Affairs and National Working Commission on Ageing  2014.9.12 24 ministries and commissions, such as National Development and Reform Commission, Ministry of Civil Affairs, Ministry of Finance, Ministry of Land and Resources 2014.10.23 Ministry of Finance, Ministry of Civil Affairs and National Working Commission on Ageing  2014.10.30 6 ministries and commissions, including Ministry of Civil Affairs, National Development and Reform Commission and Ministry of Industry and Information Technology of the People’s Republic of China 2015.1.15 The State Council

2015.2.3

2015.3.4

Titles of policies and regulations Notice on Promoting the Construction of Urban-Rural Old-Age Service Facilities Guiding Advice on Implementation of Pilot Trial of Old-Age Housing Reverse Mortgage Pension Insurance Notice on Strengthening Public Facility Accessible Remolding of Home and Residential Area for the Elderly Notice on Purchase of Old-Age Service by the Government

Notice on Accelerating and Promoting the Construction of Health and Old-Age Care Service

Notice on Construction and Perfection of Subsidiary System for Advance-­ age, Disabled Old People with Financial Difficulties Notice on Pilot Work of Old-Age Service, Community Service, Benefiting People with Information Engineering

Decisions on the Reform of Old-Age Pension Insurance System for Staff of State Organs and Employees 10 ministries and commissions, including Advice on Implementation of Encouraging Involvement of Ministry of Civil Affairs, National Nongovernmental Capital in the Development and Reform Commission Development of Old-Age Service and Ministry of Education Industry National Development and Reform Guiding Advice on Standardization of Commission and Ministry of Civil Affairs Toll Administration for Old-Age Institutional Service to Promote Healthy Development of Old-Age Service Industry

Sources: the table is formulated by the authors.

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

153

responsiveness and urgency of the attitude of the government towards the problems of the elderly, while indirectly reflecting abnormally rapid and severe realistic ­conditions of the problems of the elderly in China. Fourthly, from the perspective of policy and regulation formulation, the Chinese government’s policy making and national legislation mode is typical “plural governance,” or an administrative consultation or departmental coordination mode in common language, which typically reflects the institutional framework and role assignment of the Chinese government. Except for the policies and regulations independently issued by the National People’s Congress, the Central Committee of the Communist Party of China (CCCPC) and Ministry of Civil Affairs, most policies and regulations are released in the form of “joint issuances” by multiple related functionary ministries and commissions of the State Council, which typically reflects the segmentation and divided policies from various sources of the Chinese government. The National Working Commission on Aging (founded in October 1999) is a “deliberation and coordination institution” for the State Council to take charge of the work on aging across the nation. The National Working Commission on Ageing is composed of 27 units—namely, the Organization Department of the CPC Central Committee, Propaganda Department of Central Committee, Work Committee of Offices Directly under the CCCPC, State Organs Work Committee of the CPC, Ministry of Foreign Affairs, National Development and Reform Commission, Ministry of Education, National Commission for Democracy, Ministry of Public Security, Ministry of Justice, Ministry of Finance, Ministry of Human Resources and Social Security, Ministry of Housing and Urban-Rural Development, Ministry of Culture, Population and Family Planning Commission, State Administration of Radio Film and Television, General Administration of Sport of China, State Statistics Bureau, National Tourism Administration, China Insurance Regulatory Commission, General Political Department, National Trade Union, Central Committee of the Communist Young League, All-China Women’s Federation, and China Aging Association; this reflects the duty and responsibility segmentation of administrative power in China. It is noteworthy that this situation is by no means a unique case for welfare policies and regulations for the elderly, but a general phenomenon for the policy systems of China. These mechanisms of “each railway policeman is only responsible for part of the rail” and “co-decision making and diffusion of responsibility in multi-sectors” reflect the relatively low administrative ability of China. The last but not the least, welfare for the elderly and related titles and contents of policies and regulations of the central government reflect the welfare system construction for the elderly and the functions, roles, and positions of the central government (especially the characteristics of the government’s organization structure, operation mechanisms, decision-making models, and policy agendas). Firstly, the welfare policies and regulations for the elderly mainly include five categories of policies and regulations—namely, related laws, policies, and regulations of the central government and State Council; policies and regulations independently formulated by the State Council; policy documents jointly issued by two or more

154

J. Liu and Y. Liu

functionary ministries and commissions of the State Council; and department regulations independently formulated by certain ministries/commissions of the State Council. These reflect the typical characteristics of the complicated hierarchical structure, unclear boundaries, large quantities, and various types of policies and regulations of the Chinese government. Secondly, the titles of welfare policies and regulations for the elderly reflect the themes of government concern at different times, government action logic, and national policy targets and orientation. The titles include the following: Law of the People’s Republic of China on the Protection of the Rights and Interests of the Elderly and Related Revision, Strengthening the Law for the Elderly, Socialization of Social Welfare, Preferential Policy on the Tax of Service Institutions for the Elderly, Development on Service Industry for Provision for the Elderly, Development of Service Industry, Home-Based Care for the Aged, Allowance for the Elderly over 80  Years Old, Military Cadre’s Sanitarium, Social Insurance Law, “The Twelfth Five Year Plan” of the Development of Undertakings for the Elderly of China, Encouraging and Channeling Nongovernmental Capital Entering Provision for the Elderly Field, Strengthening Cultural Construction for the Elderly, Rural Welfare Home Project Supported by Public Welfare Fund from Lottery of the Central Government, the Year for Promotion of System Construction of Provision for the Elderly of China, Founding Permit and Management Measures of Institution of Provision for the Elderly, the Government Purchasing Service and Service for the Elderly from Social Force, Accelerating the Development of Service Industry for the Elderly, Promoting the Development of Health Service Industry, Strengthening Standardized Work of Service for the Elderly, Strengthening Planning and Construction of Facilities of Service for the Elderly, Establishing Unified Basic Pension Insurance System for Urban and Rural Residents, Urban and Rural Old-Age Insurance System Convergence, Promoting the Insurance Work of Institution of Care for the Elderly, Land-Using Policies of Facilities of Care for the Elderly, Urban Construction of Facilities of Care for the Elderly, Pilot Project of Housing Reverse Mortgage for Old-Age Pension Insurance, Strengthening Remolding Work of Home and Residential Area Accessible Public Facilities for the Elderly, Promoting Health and Old-Age Service Engineering Construction, Reform of Old-Age Pension Insurance System for Staff at Public Institution, About Welfare System Planning and Facility Construction Planning for the Elderly, Land-use for Service Facilities for the Elderly, Setting and Management of Old-Age Service Institution, Old-Age Service Mode and Home-based Care for the Aged, Policies for the Development of Old-Age Service Industry and Related Industry, Capital Source and Financing Mode of Old-Age Institutions, Basic Old-­ Age Pension Insurance System of Urban-Rural Integration for All Citizen, and all policy fields and main policy subjects in the Protection of the Rights and Interests of the Elderly and Related Revision. This clearly reflects the construction process and development track of the framework of a modern welfare system for the elderly of China.

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

155

9.3  S  tructural Defects and System Construction Quality of Welfare Policies for the Elderly of China Looking back at the historical development of the framework of welfare policies and regulations for the elderly in China, especially from the aspect of the effects of the framework construction of the welfare policies and regulations for the elderly, the effect is not as ideal as expected. The due effects of the system are displayed. The welfare system construction for the elderly is basically a superficial system construction mode, not a real intrinsic system construction mode; thus, the quality of welfare system construction for the elderly is relatively low. During the two national conferences (i.e., the National People’s Congress and the Chinese Political Conference) in 2015, the problem of supporting retired people became a hot topic once again. For example, a web survey of 2200 people was carried out by the Panel Consultation of China Youth News. In response to the question of “Are you worried about your living support after retirement?”, 71.8% of interviewees’ responded that they were worried and have no idea what situations will be faced in the future, 18.2% stated that they were not worried and that things will work out in the end, whereas 10.0% said that “it is hard to say.” The questionnaire reflected that people’s ability to spend their remaining years in comfort has become a social anxiety (Li, Qiu, & Yang, 2015). Furthermore, the welfare policies and regulations for the elderly of the central government have not timely, accurately, and effectively responded to the key problems of welfare system construction for the elderly. The policies and regulations on welfare system construction for the elderly since 1996 have been ineffective and inadequate, being in superficial system construction mode with no function. The quality of the framework design of welfare policies and regulations for the elderly of the central government and welfare system construction for the elderly is not high, and the quality of the system should be increased urgently. Based on an overview of historical experiences with modern welfare system construction for the elderly from countries across the world, especially since the reform and opening-up in China, we can clearly see that such a process is associated with 10 core problems, which make up the main body of welfare system construction for the elderly. This list includes the essential attributes of the system; the nature of provisions for the elderly; the subject of liabilities for provision and financing for the services; the value goal; the value basis; the theoretical perspective and basic principles that should be followed; the modern welfare policies and regulations for the elderly; the welfare system framework; the objective, scope, contents, and priority fields of a welfare service system; and how to timely and effectively respond to key problems during the construction process of a modern welfare system for the elderly. There is also a list of ten core questions that should be answered before the construction of welfare policies and regulations for the elderly in a system framework design and welfare service system, as follows: 1. What are the essential attributes of the services for the elderly? This is the most pivotal question because the nature of the services decides the nature of the service system.

156

J. Liu and Y. Liu

2. What are the value objectives and policy objectives of the services for the elderly? This is a specific reflection of the problem of essential attributes in the field of policies and regulations. 3. What are theoretical bases and theoretical perspectives of the services for the elderly? These are the theoretical knowledge and theoretical reflection of the essential attributes of the problem of provisions for the elderly. 4. What basic principles should be followed in the services for the elderly? The principles are the rules and code of conduct to cope with the numerous and complicated problems of provisions for the elderly. 5. What are the specific scope, contents, and priority fields of old-age services? 6. What are the financing and payment options for old-age service? They are the core embodiments of the essential attributes of old-age problems, and their nature determines who will pay for the services. 7. What are the operational mechanisms of old-age services? They define the planning, implementation, and operation of an old-age service system. 8. What are the policies and regulations of administrative control in a welfare service system for the elderly? 9. What are the related basic facilities for social services and policy guarantee measures for old-age services? They are the social environment for old-age services. 10. What are the policies and regulations of old-age services and the social effect and influence of the service system? In brief, the ten basic theoretical and policy issues in this study of the construction of a modern welfare system for the elderly provide an optimal perspective and indicator system to observe and evaluate welfare policies and regulations for the elderly of China and the quality of the welfare service system construction. Since the reform and opening up, the policies and regulations for old-age services in China and service system construction have been confronted with multiple structural and systemic problems. Such problems are long term and become even more prominent with time, which typically reflects a low quality of policies, regulations, and service system construction. The issued policies and regulations may be a mere formality—simply a response to the requirement of policy issuance—and fail to solve the key problems of old-age services, thus turning into a non-functional decision-making mode (Table 9.3). In summary, there are structural defects and systematic insufficiency in the welfare policies and regulations for the elderly of China. The main problems include the following: (1) an unclear understanding of the nature and essential attributes of the issues of the provision of elderly and old-age services; (2) an unclear responsible subject and financing subject for the provision of elderly and old-age services; (3) an unclear capital nature and subject responsible for financing for the provision of elderly and old-age services; and (4) the presence of many fundamental issues in the system of administrative control and overall institutional arrangements for the provision of elderly and old-age services. Of these, the core problem is the nature and essential attributes of the issues of the provision of elderly and old-age services.

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

157

Table 9.3  Main problems of the old-age services, related policies , and regulations defined by Chinese authorities (1996–2015) Time 2000.2

Titles of policies and regulations Advice on Accelerating Socialization of Social Welfare

2000.7

Decision on Strengthening the Work on Aging of the CPC Central Committee and the State Council

2007.3

Some Advices on Accelerating the Development of Service Industry

2008.2.

Advice on Comprehensively Promoting Home-based Old-Age Service Work

2011.9

“The 12th Five Year Plan” of the Development of Old-Age Undertakings in China

Main problems defined by Chinese authorities For a long time, the social welfare of China was handled by the state and collective. Problems of insufficient capital, few welfare institutions, and low service levels exist, which can hardly satisfy the ever-increasing demands for welfare service by the people The basis of the work on aging in China is relatively weak, which can hardly satisfy the demands of the aging population. The main problems include an insufficient understanding of the aging population, insufficient policies and regulations on the work of aging, an imperfect social insurance system, backward community management, inadequate old-age service facilities or service website construction, weak old-age ideological and political work, frequent violations of the legal rights and interests of the elderly The overall supply in the service industry is insufficient, with disadvantages such as irrational structures, low service levels, weak competitiveness, a low contribution to the national economic development, inadaptability to national economic development, inadaptability to building a moderately prosperous society in an comprehensive way, inability to build a harmonious socialist society, inadaptability to economic globalization, incomprehensive opening up, and new situations At present, home-based old-age services in China have disadvantages of insufficient supply, relatively low proportions, low quality, and an inability to satisfy the ever-increasing service demands from the aging population In the rapid development of the aging process, the conflict of old-age undertakings and relatively backward work on aging becomes more prominent, mainly manifested by an imperfect social old-age pension insurance system, backward welfare old-age service facilities and service website construction, insufficient development of the old-age service market, insufficient supply, relatively weak old-age social management work, and violations to the rights and interests of the elderly from time to time (continued)

158

J. Liu and Y. Liu

Table 9.3 (continued) Time 2011.12

2013.9.6

Titles of policies and regulations Planning of Construction of Social Old-Age Service System (2011–2015)

Some Advices on Accelerating the Development of Old-Age Service Industry 2013.9.26 Guiding Advice on Purchase of Service from Social Force by the Government

2014.2.

2014.5.

Main problems defined by Chinese authorities The construction of a social old-age service system of China is still in the initial stage, with problems of inadaptability to new situations, new tasks, and new demands, which mainly manifested by a lack of overall planning, a lack of integrality and continuity of system construction, a serious shortage of community old-age services and beds in old-age institutions, a prominent imbalance between supply and demand, crude facilities and simple functions (which can hardly provide multi-­ aspect services of nursing care, medical rehabilitation, and spiritual consolation), an irrational overall arrangement, a development imbalance among regions and between urban and rural areas, insufficient government investments, a limited nongovernmental investment scale, low professionalism of the service team, unsustainability of industry development, poor implementation of preferential policies issued by the state, poor service standardization, and industry self-­ regulation and market supervision that need to be strengthened Overall, there are prominent problems of insufficient old-age services and product supplies, imperfect market development, and imbalanced urban and rural, etc.

There are prominent problems with low-quality and inefficient public service, inadequate scale, and imbalanced development. Therefore, there is an urgent need for the government to further strengthen the public service function, innovate the supply mode of public service, effectively mobilize social forces, and construct a multi-layered and multi-method supply system of public service to provide more convenient, rapid, high-quality, and highly efficient public services There are still problems with an imperfect standardized Guiding Advice on system of old-age services and unstandardized market Strengthening Standardization Work of service behavior Old-Age Service Notice of Promoting the In recent years, with the acceleration of urbanization and an increase of the urban aging population, there are Construction Work of Urban Old-Age Service ever-increasing prominent problems of limited land use for the construction of urban old-age services in China, Facilities insufficient total volume, and backward facilities, which have increasingly become the bottleneck factor that is restricting the development of the old-age service industry (continued)

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

159

Table 9.3 (continued) Time 2014.7.

2014.9.

2014.10.

Titles of policies and regulations Notice on Strengthening Public Facility Accessible Remolding Work at Home and Residential Areas for the Elderly Notice on Accelerating Construction of Health and Old-Age Service Engineering

Main problems defined by Chinese authorities Accessible environment construction is actively promoted in various regions to promote the remodeling of home and residential areas for the elderly and to effectively improve accessible environments. However, there is still a large gap between the objectives of the old-age service industry and the demand for old-age services After several years of development of healthcare, sports, and fitness undertakings for the elderly, the overall volume is generally insufficient, with generally irrational arrangements and structures and obvious backward development In recent years, the social security system, such as basic Notice on Establishing old-age pension insurance, basic medical insurance, and Perfect Subsidiary the urban-rural basic living allowance, have solved basic System for Advance-­ Age, Disabled Old Man living problems of the elderly; however, a system with Financial Difficulty guarantee for old-age services for advanced-age and disabled elderly with financial difficulties is still lacking

Sources: the table is formulated by the authors.

The nature and essential attributes determine the value objective and policy objective of an old-age service system, the responsible subject and responsible financing subject for the provision of elderly and old-age services, the service targets of an old-age service system, the system of administrative control, the overall institutional arrangement for the provision of elderly and old-age services, and the quality of the provision of elderly and old-age services. In brief, the main systemic problem is an insufficient and unclear understanding of the essential attributes of the provision of elderly and old-age services by the decision maker. The problems of structural defects and systematic insufficiency in welfare policies for the elderly of China triggered quality issues in the policies, regulations , and system construction. China should keep a foothold at home and face the world, fully borrowing useful experiences and lessons from the old-age welfare policies and service systems of other countries. At the same time, China should avoid detours, starting all over again from the beginning, or ignoring the universal rules of social development or modern welfare system construction; all of these will waste the unique “late-mover advantage” of China as a developing country. On the contrary, China should reduce the social cost and social risk of modern system construction, combine universal rules with Chinese characteristics, and increase the quality of welfare policies and regulations for the elderly of China and old-age service system construction. System quality is a core concept with rich connotations and extensive denotations; it refers in general to the value, theoretical basis, objective, principles, scope, contents, service targets, service processes, financing responsibilities, public administration of system construction, and overall quality of the entire institutional system. Beyond a doubt, system quality is the historical product of modern social system construction, with quality and demands of the highest levels. Throughout the

160

J. Liu and Y. Liu

social development of human beings, the system quality generally starts from microscopic, specific, and local objects, with activities of material quality, product quality, technical quality, and service quality. It then goes through medium-scope policies, regulations, and service system quality until it is finally upgraded to macroscopic, overall, comprehensive, and systematic system quality. All of these states reflect the constant improvement of a modern system construction level. The quality system of modern welfare policies and regulations and a welfare service system for the elderly are mainly composed of the following main indicators: value quality, service quality, theoretical basis quality, policy objective and task objective quality, basic principle quality, service target quality, service scope and content quality, service method and technical quality, service process quality, service procedure and service standard quality, capital nature and service financing quality, quality of service staff professionalism, overall quality of the service institution, government response quality, policy and regulation quality, overall quality of the national system of administrative control, and service effect and influential quality. The quality system reflects the overall system quality. The four most important, pivotal, and core quality indicators are the value, service nature, policy objective, and capital nature. More importantly, the evaluation standards are different in different quality fields, reflecting the specificity and internal logic in each specific field. The value quality evaluation standard mainly refers to value modernity, such as welfare and well-being values, with different connotations and denotations for different individuals (Liu, 2015). The main evaluation for the standard of service nature quality is the accuracy of the decision-maker’s understanding of the service essential attributes to see through appearances to the essence. The main evaluation standards of the theoretical basis quality are correctness, applicability, and pertinence, which provide the correct theoretical guidance. The main evaluation standards of policy target and task target quality are precision and accuracy, with no operational problems with the service target. The main evaluation standards for the basic principal quality are feasibility, applicability, and operability, which provide guidance for facing the numerous and complicated social realities. The main evaluation standard of service subject quality is to serve the people who really need help; the social service may help to realize social equality. The main evaluation standards of service scope and service contents are pertinence and correctness—that is, whether the service is what the service targets need (Ryan Doyall Waits (UK) & Wang, 2008). The main evaluation standards of service method and technical quality are simplicity, feasibility, effectiveness, convenience, and the ability to fully utilize the applicability of tools. The main evaluation indicators of service process, service procedure, and service standard quality are process clarity, procedure standardization, and first-rate standards. The main evaluation standards of capital nature and service financing responsibility quality are who should pay and who is the ­responsible service financing subject. The main evaluation standards of the professionalism of service staff are the values of professionalism, attitude, knowledge, and a practical ability to solve actual problems. The main evaluation standards of the overall quality of a service institution are the nature, value, distant view, social mission,

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

161

and governance structure of the service institution. The main evaluation indicators of government response quality are the time required for the government to respond to social problems and the effects achieved by the policies and regulations. The main evaluation indicators of the overall quality of a national system of administrative control are the structure, functions, and efficiency and management effects of the system of administrative control. The main evaluation indicators of the service effect and service influence are the target-attain rate, the effect of the problem solved by policies and services, and the active influence. In brief, the basic characteristics of system quality are the macroscopic view, totality, comprehensiveness, and systematic properties, which are the optimal indicators of a political culture (Yang, 2015). In summary, since the reform and opening up, the course of welfare policies and regulations and a service system for the elderly of China has historically changed. The unclear nature and value of these policies, regulations, and service system, along with the relatively low theoretical basis and policy target quality, suggest that the quality of welfare policies, regulations, and the service system urgently needs to be improved. The welfare system construction for the elderly has obvious characteristics of a non-functional and superficial system construction mode, but not of an intrinsic system construction mode, which has mainly manifested in three aspects: 1. There is a fundamental defect in the decision-maker’s understanding of the essential problems and attributes of provisioning elderly and old-age services, which is the most pivotal problem. Because the nature of the problem determines the overall policy framework and institutional arrangement, as well as the influence brought by, this is also a comprehensive, structural, and systematic problem. 2. There are many structural and systematic dilemmas in the existing welfare policy and regulation framework and service system for the elderly, and the quality of policies and systems is not high. For example, there is a lack of social responsibility for problems in the provision of services and no responsibility boundaries between the state, market, enterprise, community, family, and individual (Li, 2006). 3. In the actual implementation and effects of policies, regulations, and service system for the elderly, the existing policy and service quality are less than satisfactory. In the 30 years of reform and opening up, the central government has issued more than 30 national policies and regulations. However, the problem of how to provide for the elderly has become increasingly severe. In brief, the quality of the superficial system construction mode of old-age services is worrying. At present, an intrinsic system construction mode is urgently needed. The quality of policies, regulations, and service system for the elderly of China is not high. The non-functional and superficial system construction modes are prominent. Furthermore, the causes of the highly deficient functional and intrinsic system construction modes are numerous, complicated, diverse, and by no means accidental. China is now at a historical junction of a comprehensive and rapid structural

162

J. Liu and Y. Liu

transition from a traditional agricultural society to a modern industrial society. One of the basic characteristics of this period of major social structural transition is the high interweaving of traditional system factors and modern system factors, the mutual influence of new and old factors, the competition between new and old forces, the collision of new and old concepts, and traditional and modern mixture modes (Carl, Feng, & Liu, 2007). Chinese society is now also in a transition from a traditional society to a modern society. Traditional thinking and behavioral habits are still prominent, especially in the Chinese traditional agricultural society, which deeply affect the policies, regulations, and service system for the elderly. Modern social culture is characterized by a realistic pragmatism, with an objective, rational, and non-evasive attitude toward social problems (James, 2012). However, President Xi Jinping’s state governance and administration ideas are practical and realistic, face difficulties directly, and focus on the quality of system construction (Propaganda Department of the Central Committee of the Communist Party of China, 2014). Because Chinese society is basically still a traditional agricultural society, many citizens lack an awareness of their modern rights and welfare. Furthermore, the unique and prominent values of the Chinese nation are still responsibility over freedom, obligations over rights and interests, group over individual, and harmony over conflict. At present, the policies, regulations, and service system for the elderly are based on family-based care for the aged and have a profound social basis (Chen, 2015). At present, the social welfare concept in narrow sense is still prominent in Chinese society. A mainstream concept is social security, which has taken a unique political and cultural tradition: the concept of social security is big, and the concept of social welfare is small.” Policies and regulations are led by social security, which may repress citizen’s rights and interests; the social welfare service is the responsibility of the state subject (Jing, Bi, Gao, et al., 2011). For a long time, social system framework design and policy, as well as regulation decision making, were conducted from top to bottom. The degree of participation of the public and related parties of interest was generally low, as was the transparency of development planning, national legislation, major decision making, policy implementation, and public administration processes. The implementation of scientific and democratic decision making was rather difficult; in particular, the participation of experts and scholars was limited (Daiy, Yu, et al., 2002). The replicability, popularization, and degree of system innovation were relatively low. Therefore, the quality of national social policies, regulations, and system construction urgently needs to be improved. Currently, China is in a historical process of social modernization and construction of a welfare state. The functions and roles of the country are undergoing rapid transformation. Economic development is still the preferential field of state policy, and social welfare is still regarded as a burden of economic development (Speeper, Yang, et al., 2004). However, the development status of political philosophy , political will, political wisdom, political commitment, and political civilization of a country are quite important. The historical experiences of the construction of a welfare

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

163

state and welfare society in various countries of the world have proven that political philosophy decides social philosophy and social welfare philosophy. A welfare society can only be built after the establishment of a welfare state, and the establishment of a welfare state and welfare society is a stage that cannot be avoided for social modernization. Beyond a doubt, the construction of a framework for a modern social welfare system with Chinese characteristics has become China’s greatest strategic development issue and a preferential field of study (Whitek et al., 2003). Fortunately, the Chinese government has clearly proposed, planned, sketched, and constructed a welfare society—a moderately prosperous society. In other words, “a moderately prosperous society” is a Chinese version of a welfare society. According to the country’s two 100-year development goals, China should complete the construction of a moderately prosperous society in 2021. Therefore, China’s development goal is the construction of an overall moderately prosperous society by 2021 (The People’s Daily Commentator, 2015). In brief, China’s political modernization, economic modernization, social modernization, cultural modernization, and welfare development conditions are maturing with each passing day. The current low construction quality is the inevitable result of the co-effect of political, economic, and cultural factors.

9.4  Brief Discussion and Conclusion Since 1949, the development stages for the welfare policies, regulations, and service system for the elderly of China have always been clearly defined by the characteristics of the times, the obvious historical track, and the development trends of a system transition. The period from 1949 to 1981 was the era of socialism, collectivism, and traditional times of respecting the old and cherishing the young. The period from 1982 to 1999 was the formation period for problems with the provision of old-­ age care and policies, with these problems becoming political and social issues . However, the government had no clear policies for the elderly yet; there were problems with the provision of services for the aged, but no policies for the elderly. The period from 2000 to 2014 was the basic formation period of a welfare policy and regulation framework and service system for the elderly of China. During this period, the problems of the elderly and provisions for the elderly first became priority issues in the social policy agenda of China, along with major developments of in the old-age policy and service system. The year 2014 was not only the first year for China to deepen the reform, but also the first year of construction of the country under the rule of law. It was the first year for China to construct a modern welfare system for the elderly. In addition, the year marked the historical prelude of a modern welfare system framework and welfare service system framework for the elderly of China, so this year was a milestone. The problems of the elderly are major, urgent, and severe social and political issues, as are the problems of the era with the construction of a modern welfare system for the elderly.

164

J. Liu and Y. Liu

Since the founding of the People’s Republic of China in 1949, the problems of the elderly and national policies experienced the historical development track of starting from scratch, from small to large, from local to whole, from individual troubles to social problems, from social concerns to political issues, from the margins to the mainstream, from welfare policies to welfare system construction, which clearly reflect the transitional track of China’s society and social welfare modernization. Meanwhile, the old-age service policies and service system of China are in a rapid transitional period with a clear system framework, un-finalized policies and systems, and great variability and rapid development, which reflect the comprehensive and rapid transformation of the social structure of China. More importantly, welfare policy and service system construction is in a pure, natural development mode; no experiences and lessons have been borrowed from developed countries, and no late-mover advantages and late-mover effects from developing countries have been fully used. Therefore, the political fashion, political imitation, political transplant, and system learning abilities in the social political field are based on social conditions. The system learning ability is not natural, and the determinants and influencing factors for the systematism of the social policy mode are diverse. Since the 1990s, the welfare policies, regulations, and service system framework for the elderly of China have taken shape, typically reflecting Chinese political philosophies, power structures, social structures , cultural characteristics, and living conditions as well as the relationships among the state, market, and society. Overall, the welfare policies and regulations for the elderly at the level of central government are mainly composed of four levels—national laws, documents of the Central Committee of the Communist Party of China and State Council, administrative laws and regulations and documents of the State Council, and documents of functionary ministries and commissions of the State Council—reflecting the structure, functions, and roles of the central government. Meanwhile, the service system framework for the elderly of China has an extensive scope and content, with the main part composed of an economic guarantee and a service guarantee. At present, the basic conditions of old-age service include an insufficient economic guarantee and deficient service guarantee, especially a lack of “decommercialized” and “welfare”natured specialized and individualized old-age services; in addition, the old-age service turns from a simple social service to a severe political problem. The construction of an old-age service system with Chinese characteristics has become the key to constructing a moderately prosperous society. More importantly, looking through the welfare policies and regulations and service system framework for the elderly of China, the quality of policies and regulations, the service system, and the overall welfare system for the elderly is not high. Distinctive systematic characteristics are in urgent need of improvement, with typical examples of a non-functional , superficial system construction mode. The ­political factors, economic factors, social factors, and cultural factors all affect the quality of the system construction. In brief, the welfare system mode has transformed from a “city-based and work-unit-Welfare State” to a “society-market-welfare state.”

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

165

The structural defects and system deficiencies of welfare policies and regulations for the elderly of China trigger quality issues in the system construction. The system quality is an optimal perspective for evaluating political modernization and political civilization, especially national governance ability and governance levels, and it has important political significance. There is no such thing as flawless and ideal system quality; rather, a system arrangement with relatively high system quality is possible, which shows its relative nature. The system quality has limits characterized by the times. An optimal system arrangement reflects the highest level of human understanding and political civilization of the current time. Overall, the system quality is mainly composed of quality indexes, such as value quality, service nature, theoretic basis, political and task objectives, basic principles, service targets, service scope and contents, service methods and techniques, service processes, service procedures and standards, capital nature and service financing responsibility subjects, professionalism of the service staff, overall service organizations, government response and policy and regulation quality, overall quality of the national system of administrative control, service effect, and service influential quality, which reflect the overall system quality. Among them, the three most important, pivotal, and core quality indexes are value quality, service quality, and policy target quality. The core of the modern social system construction is value construction, and the value quality determines the system framework and service system quality. Acknowledgments  This study was a phased objective of a key project of the National Social Science Fund led by Professor Liu Jitong (15ASH00) as the Study of Modern Social Welfare System Construction with Chinese Characteristics. It is hereby clarified and acknowledgements are extended. The authors thank the doctoral candidate Dan Wang for the contributions to the article proofing who is from the Medical Humanities Institution of Peking University.

References Carl, P., Feng, G., & Liu, Y. (Trans.). (2007). The political and economic origins of our time. Hangzhou: Zhejiang People’s Publishing House. Chen, L. (2015, March 4). Full understanding of China’s unique values—From the comparison between China and the West. Beijing: People’s Daily. Cheng, H. (2010, February). Perfecting social welfare policies for the elderly is the first choice for social welfare reform in China. Beijing: Social Security Research. Cui, N. (Ed.). (1994). Civil Administration in Contemporary China (two volumes). Beijing: Contemporary China Press. Daiy, T. R., Yu, F.(Trans.). (2002). Top-down policy formulation. Beijing: China Renmin University Press. Ding, X. (2015, February 12). Qingdao explores the medical care insurance system: Whether the combination of medical care and rehabilitation can enable the disabled elderly to rely on their retirement pension. Beijing: China Youth Daily. Duojicairang. (2001). The research and practice of China’s minimum living security system. Beijing: People’s Publishing House.

166

J. Liu and Y. Liu

He, C. (2010). Modern science: State-developed scientific principles. Beijing: Science Press. Hu, X. (Ed.). (2009). Towards harmony: 60 years of social security development in China. Beijing: China Labor Social Security Press. James, W. (2012). Pragmatism: New names for some old ways of thinking. Beijing: Commercial Press. Jing, T., Bi, T., Gao, H., (2011). Contemporary Chinese social welfare thought and system: From small welfare to great welfare. Beijing: China Social Press. Li, F. (2006). China-Japan comparative study on old-age welfare policy—Government and civil responsibility sharing. Dalian: Master’s degree in 2006 from Northeastern University of Finance. Li, S. (2015, March 1). There are five major issues in the open government information that need to be resolved. Beijing: China Youth Daily. Li, L., Qiu, C., & Yang, M. (2015, March 12). 71.8% of the respondents were worried about their retirement: The two officials of the Ministry of Human Resources and Social Security were popular in National Congress. Beijing: China Youth Daily. Liu, J. T.(2011a, February). The coming of the era of “social policy framework” and “social legislation” with Chinese characteristics. Chengdu: Social Sciences Research. Liu, J. T.(2011b, October). The historical types of health policies and regulations in China and the strategic transformation of health governance models. Jinan: Dong Yue Lun Cong. Liu, J. T.(2015, May). The concept of modern social welfare and the construction of social welfare system with Chinese characteristics. Harbin: Heilongjiang Social Sciences. Ministry of Labor and Social Security, The Department of Insurance and Welfare. (Ed.). (1989). The historical materials of China’s employee insurance welfare. Beijing: China Food Press. Mu, G. (2015, February 6). Be wary of the “disease of aging.” Beijing: Health News. Office of the Secretary General of the State Council, General Division of the Office of the Central Compilation Committee. (Ed.). (2009). Central Government Organization 2008. Beijing: Party Building Reading Press. Propaganda Department of the Central Committee of the Communist Party of China. (2014). Reading list of important speeches by General Secretary Xi Jinping. Beijing: People’s Publishing House. Ryan Doyall Waits (UK), & Wang, Y. (2008). The need theory of human being. Beijing: Commercial Press. Shao, T., & Bi, X. (2014, May). A review of domestic research on the government’s back stress in academic circles in recent years. Fuzhou: Journal of Fujian Institute of Public Administration. Speeper, N., Yang, J., (Trans.). (2004). Changes in state functions: Privatization and welfare reform in industrialized economies and transitional economies. Shenyang: Liaoning Education Press. Sun, H. (1994, October). The essence of social welfare policy: Social control and “de-­ commodification.” Shanghai: Social Sciences. The CPC Central Committee. (2006). Decision of the CPC Central Committee on several major issues concerning the construction of a harmonious socialist society. Beijing: People’s Publishing House. The CPC Central Committee. (2014). Decision of the CPC Central Committee on comprehensively promoting certain important issues of governing the country according to law. Beijing: People’s Publishing House. The Nanjing Government. (2014, October 13). The Nanjing government hires sons and daughters to take care of parents and pays them monthly. Beijing: Sohu News. The People’s Congress of Beijing Municipal. (2015, January 26). The People’s Congress of Beijing Municipal deliberations on the Regulations of Home-based Care for the Elderly clearly define the responsibilities of all parties for the first time. Beijing: Beijing Daily. The People’s Daily Commentator. (2015, February 26). Let the all-round well-off society agitate the Chinese dream—Secondly, coordinate and promote the “four comprehensiveness.” Beijing: People’s Daily. Wang, S. (2007, April 6), Historical changes from economic policies to social policies. Beijing: China Economic Times.

9  Social Construction, System Defects, and System Quality of a Welfare Policy…

167

Wang, S., & Hu, A. (1993). China National Capability Report. Shenyang: Liaoning People’s Publishing House. Whitek, W. H., Federico, R.C., Xie, J.J., (Trans.). (2003). Social welfare in today’s world. Beijing: Legal Press. For the history of the Office of the National Committee on Ageing and the China Association for the Aging, please refer to the official website of the Office of the National Committee on Ageing: www.cncaprc.gov.cn. Yan, Z. (Ed.). (1987). Wage welfare and social insurance for contemporary Chinese employees. Beijing: China Social Sciences Press. Yang, Z. (2015, March 18). The high prices make consumers discouraged, and the three major problems of shortage of land, financing, and nursing care hinder the development—Why is the development of demanding people’s nutritional services slow?. Beijing: Workers Daily. Zhou, T. (Ed.). (1987). Contemporary China’s economic system reform. Beijing: China Social Sciences Press, 1984.

Chapter 10

Social Organisations and Old Age Services in Urban Communities in China: Stabilising Networks? Bingqin Li, Lijie Fang, Jing Wang, and Bo Hu

10.1  Introduction In recent years, China has experienced rapidly increasing demand for old age care and relevant services for elderly people, as a result of the rapid growth in China’s older population (Peng, 2013). According to the 2015 Social Service Development Statistical Communique (Ministry of Civil Affairs, 2016), by the end of 2015, China’s population aged 60 and over had reached 222 million—equivalent to 16.1% of the total population. Further, the population aged 65 and over had reached 143.86 million—about 10.5% of the total population. According to an estimate by Hu and Yang (2012), the actual old age dependency ratio reached 5:1 by 2012, which is a greater level of dependency than the 8:1 estimated by the official statistics. This ratio will reach 3.5:1 by 2020. According to the estimate of the 2013 Human Development Report of China (UNDP China, 2013a, 2013b), by the end of 2011, some 9.1% of Chinese people were older than 65. According to this report’s estimate, this figure will rise to 18.2% by 2030—higher than in most industrialised countries. In addition to the demographic changes, China’s old age care services are challenged by the country’s changing social and economic situations. As the overall income increases, older people’s lifestyles and demand for cultural activities are also different to those of the past. Older people have begun to demand more convenient, more varied and higher quality services and facilities. These changes have created serious challenges for the existing old age care system. B. Li (*) Social Policy Research Centre, UNSW, Sydney, Australia L. Fang · J. Wang Social Policy Research Centre, Institute of Sociology Chinese Academy of Social Sciences, Beijing, China e-mail: [email protected]; [email protected] B. Hu London School of Economics and Political Science, London, UK © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_10

169

170

B. Li et al.

Faced with these newly emerging needs, demands, and higher expectations for more personalised services, the state—which used to be prescriptive and paternalistic—has recognised that it is impossible to play the paternalistic role as it has done in the past, by prescribing which services people can access and delivering them at the minimal level. Instead, the government must now rely on other actors to cope with the mounting challenges. With the involvement of alternative providers, the state does not always need to be directly involved in service delivery, while the financing of services can also be diversified, which may lead to lower service costs and higher user satisfaction. Partly due to the need to meet these emerging social needs more efficiently, the state has introduced reform in two areas of old age care (Yan & Gao, 2007; Howell, 2012) as follows: • Starting from 2000, a community-based service network was introduced to guarantee that services are delivered close to where people live. • Starting from 2013, contracting social organisations (SOs) to deliver social services. These two changes mean that services will be increasingly delivered at community level by non-government providers. In theory, such changes should allow more responsive service provision that is adaptive to diverse and changing social needs and can mobilise resources outside the public finance system (Stepan & Müller, 2012). These changes have profound meaning for the state of old age care in China. There is booming service provision in the sector of old age care. According to the Statistical Communique published by the Ministry of Civil Affairs in 2016, by the end of 2015, there were 116,000 service providers or facilities nationwide (23.4% higher than the previous year), with 6.727 million beds available to older people in need of care (16.4% higher than the previous year). On average, there were 30.3 beds for every 1000 older people. However, despite the fast growth in services, people remain cautious about the current trend to contract out social services to SOs. This concern is not solely about the service per se, but also about the sustainability of the system (Teets, 2013). In this chapter, we argue that the existing studies and critiques on the introduction of SOs to service delivery have often made hasty judgements. The eagerness to see quick results can stand in the way of developing healthy relationships between stakeholders. Like any new mechanical system, if not more so, a new policy implementation system takes time for all the actors to learn, negotiate, and adapt. Stakeholders need to readjust to the new roles they have assumed in the new networks established as a result of introducing SOs to the system, and it takes time for an established network to be reshaped and re-stabilised. Only when the networks are stabilised can the discussion of sustainability be meaningful. This means that, at this stage, it is necessary to make an effort to examine what has occurred during the process of framework formation in order to observe the challenges to stabilisation and sustainability, and to examine how stakeholders have adapted to or coped with the changes. Studying this process may also help us think at a theoretical level about whether some of the reactions and factors can be generalised to different policy contexts.

10  Social Organisations and Old Age Services in Urban Communities in China…

171

In the following sections of this chapter, we first examine the characteristics of old age services, and argue that delivering social services involve a complex system that can only be achieved with the participation and coordination of multiple stakeholders. This means that the system is unavoidably a network of stakeholders comprising actors in both formal and informal sectors. We then discuss the theories on network transition and to establish a framework to understand the process of adjustment after new actors joining an existing network. We use the cases of three cities in China in an analysis to examine which factors help a city adapt to the changes more effectively. In the conclusion, with reference to the experience of these Chinese cities, we discuss the current state of the network stabilisation process in different contexts and explore the research outcomes. This research contributes to understanding network transition by establishing the role of community features.

10.2  The Acute Need for Old Age Services According to the Chinese Health and Retirement Longitudinal Study (CHARLS), in 2011, about 30% of people aged 70 and above in China needed some type of old age care or social service. This rate increased to 50% for people over 80. As the population ages, the demand and need for old age services will continue increasing (Fig. 10.1). The unsatisfied demand and need for old age services are becoming more serious as people’s lifestyles change. As Chinese society becomes increasingly Westernised and experiences increased migration as a result of urbanisation and industrialisation, the living arrangements of Chinese families are changing rapidly. A study by found that, in 2010, both in rural and urban China, the proportion of older people living with their sons was significantly lower than the proportion in the Fifth Census

Urban

Rural 11.6% 9.1%

16.8%

15.6%

3.8%

Living alone

9.2% Living with spouse 39.9%

30.0%

35.0%

29.2%

Living with at least one son

Fig. 10.1  Living arrangements of older people in China. Source: Using CHARLS Data

172

B. Li et al.

of China in 2005. It is expected that the proportion of older people not living with their children will continue to increase. According to the Chinese Family Development Report (2015) (National Health and Family Planning Commission, 2015), at the end of 2014, nearly 10% of older people’s households comprised single-person households, while only 41.9% included two older people (National Health and Family Planning Commission, 2015). Independent living has many benefits for older people, but requires corresponding social services as support. In China, although children and spouses remain the main caregivers, the above report indicated that 32.4% of people aged over 60 and living alone could not receive help when they encountered difficulties. The report also indicated that 65.3% of older people with a partner were cared for by their partner, and only 11.6% were cared for by their children. Figure  10.2 indicates the role of different types of caregivers, according to the type of living arrangement. The CHARLS data also showed that institutional care had not gained much importance by 2010. By the end of 2014, on average, older people mainly relied on themselves and their families to cope with their daily needs. Their usage of care services primarily comprised healthcare. The type of social care services in rural areas mainly comprised health examination and consultation, with about 27% of older people receiving this service. Meanwhile, 7.5% of older people had received medical care, 6.8% of older farmers had received some help with their farming, and 4.4% of older people had younger people accompany them to visit a doctor (National Health and Family Planning Commission, 2015). However, there is a greater demand for social services. At national level, the proportion of older people who actually received social services is still considered low, even by 2014. Thus, it is important to determine why—after all the excitement of introducing SOs—the demand for these services is still far from being met.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

No one helped

institute

other relatives

Living alone

Living with Living with Living with Living with spouse at least one daugher other son and other people(no child)

Children or Children's spouse

Fig. 10.2  Caregivers by living arrangement (2010) . Source: Using CHARLS Data

10  Social Organisations and Old Age Services in Urban Communities in China…

173

10.3  The Complexity of Old Age Services The content of old age care services can differ. Some people regard it as care for older people and other people regard it as a system that helps older people lead an active life. China’s old age care is at a turning point from a system that focuses on ‘care’ to a system that facilitates active ageing. According to the definition of the World Health Organization (2013), active ageing is ‘the process of optimising opportunities for health, participation and security in order to enhance quality of life as people age. It applies to both individuals and population groups’. This approach requires a more comprehensive and personalised service system that can facilitate inter-professional collaboration (Hean & Smith, 2013). Given that Chinese society’s need is far beyond old age care, in this chapter, we use the term ‘old age services’ to describe the whole system that provides various services to the older population. Existing studies have revealed the multiple facets and complexity of old age services. For example, an old age service system can involve multiple policy areas, such as buildings and infrastructure, services for care, housing, information and communication platforms, community health services, citizens’ participation and employment, assessment of respect and social inclusiveness, and so forth (UK Urban Ageing Consortium, 2014). The operation of an old age service system requires inter-professional and departmental collaboration (Green, 2013; Plouffe & Kalache, 2011; Steels, 2015), which requires collaboration and participation with multiple stakeholders, such as service providers, non-government organisations (NGOs), private businesses, caregivers, and other members of civil society. The system usually includes formal and organised services, as well as informal forms of delivery (Everingham, Petriwskyj, Warburton, Cuthill, & Bartlett, 2009). Older people are not only users of services, but may also contribute to the formation and development of the service system (Sandhu, Bebbington, & Netten, 2006; McLeod, Bywaters, Tanner, & Hirsch, 2008). Therefore, it is necessary to involve older people in the construction of a new system and have their voices represented (Lui, Everingham, Warburton, Cuthill, & Bartlett, 2009). In a country with multiple levels of government, old age services also involve multiple levels of government, which need to consider the role of central governments and the local service network (Johansson & Borell, 1999). Further, there needs to be consideration of the relationship between funding and responsibilities at the corresponding levels of delivery (Kröger, 2011). Older people, especially frail elderly people, have to cope with physical constraints when they participate in social activities (Le Bihan & Martin, 2006). Thus, they can only take advantage of resources and opportunities for social participation when appropriate access is available. This means that there needs to be infrastructure or human support to facilitate connectivity (Gilroy, 2008; Buffel & Phillipson, 2012). However, the definition of service radium can be different for different services. Moreover, there is geographical variation in access to care, which leads to different needs across regions (van Campen & van Gameren, 2005). This means that old age services can also be complex in spatial terms.

174

B. Li et al.

In addition, older people’s social needs change over time. Old age services have expanded from old age care to using services that prolong independent living and lead to an active old age (Lui et  al., 2009; Phillipson, 2011; Fitzgerald & Caro, 2014). Older people’s varied needs cannot be satisfied by the older style of government provision of social services. There is growing demand in China for more local, personalised and home-based services (Johansson, Sundström, & Hassing, 2003; Feng, Liu, Guan, & Mor, 2012). Facing such complexity, the governance of old age service becomes particularly relevant. The system must mobilise multiple sources of funding and stakeholder participation and reflect the needs of the older population. It must consider the spatial and temporal effectiveness of various services, and how to achieve the desired outcomes. The WHO (2014) stated a basic principle—that not one single government agency, organisation, or industry can assume all the responsibilities of developing a society that is friendly to older people. This can only be achieved via integrated planning and service provision (WHO, 2014). This confirms the situation in China—that the old-fashioned state social service system can barely cope, and the state realised that it had to handle the pressure differently (Hsu & Hasmath, 2014). However, it remains unclear whether the new multiple stakeholder networks can deliver and sustain the desired outcomes. Thus, in this report, we examine how the old system has coped with the shock and responded to the changes. We also seek to determine whether the local system is in the process of becoming more stabilised.

10.4  Existing Studies on Network Evolution and Transition China’s reform of its social service delivery system demands a closer look at whether the new system is able to last. Internationally, there is some experience in other countries showing that introducing NGOs as service deliverers does not always work (Kim, 2015). The viability of NGO service delivery has often been analysed from the perspective of the state–NGO relationship—that is, when the state in weak civil society plays a larger role (Jing & Besharov, 2014; Hewitt de Alcántara, 1998), or vice versa (Aldrich, 2016). Following this logic, big society often come together with small government (Boychuk, 2007), especially during times of austerity, when small government becomes a more appealing solution (Lowndes & Pratchett, 2012). Based on this, it would be logical to conclude that, in China, the reform to contract out social services to NGOs and other civil society organisations is bound to fail, as the Chinese government imposes strong leadership. However, this line of argument does not take into account the governance of the state–civil society relationship. In addition, it takes a binary and often oppositional view on the state and civil society, which does not explain the much more complicated relationship between multiple actors. Therefore, we argue that it is more relevant to perceive the social service delivery system as a ‘network’ that indicates a cluster of nodes that are linked with each other, either formally or informally, to deliver certain outcomes. Therefore,

10  Social Organisations and Old Age Services in Urban Communities in China…

175

introducing new actors to a service delivery system is like shifting from an existing network to a new network. It is difficult to determine whether the shift will be successfully achieved, as such a shift takes time. However, by examining the process of transition, we may generate some insights to the more complicated relationship between the state and other actors who are members of the network, and capture the barriers that may prevent a successful network shift. By ‘successful’, we refer to the attainment of a relatively stable network that may last in the future, unless challenged by new external factors. Examining the formation and evolution of a network requires us to adopt a lifecycle approach. Mays et al. (1998) categorised the network lifecycle into six stages: expansion, maintenance, formalisation, migration, ongoing evaluation, and termination. Weiner et al.’s (2000) ‘lifecycle model’ has four phases: emergence, transition, maturity, and critical crossroads. Swann and Morgan (1992) introduced three stages of network development: forming, storming, and norming. Forming is the initial stage, which involves ‘cooperation’ and efforts to share (Swann & Morgan, 1992, p. 41). The storming or coordination stage is prone to conflict, as members attempt to reach consensus and identify tasks and roles. During the norming stage, collaboration is achieved as members have higher morale, have greater trust, and are open to each other. Each of these models assumes that the network follows a process of development. The study of network transition is different to network evolution, as the former does not consider the lifecycle of a given network. Network transition refers to the process of a shift from one network to another. There are scant theoretical discussions of network transitions per se, apart from a small number of studies in the business management literature (e.g. Madhavan, Koka, & Prescott, 1998 on the reshaping of interfirm relationships by industry events; Huixia & Lingwei, 2011). However, there are some discussions on the relationships between new actors and existing network members. Introducing new actors may shock the system and lead to the formation of a new network. It may change the structure of the existing network and result in functional changes, such as new members, new resources, and new services being introduced to the network. The old network members adapt their behaviour shift from one stabilised stage to the next (Rhodes, 2007). New members joining a network often creates new network goals (hans Klijn, 1996); however, it is not guaranteed that these new goals can be achieved. For example, if the existing members are not supportive of the new members, a stable network may not be achieved. This can materialise via three scenarios: (1) The new members are excluded by the existing members from being part of the decision-making process, and existing members tend to collude to make decisions that are biased against the newcomers. As a result, the effective network is not very different from its earlier state. (2) Some existing network members are excluded, and the new members work together with the non-excluded members; however, the goals of the network have changed. (3) It is impossible for the new members and old members to work together, which leads to a crisis in the network and may even lead to the breakdown of the entire network. Provan and Kenis (2008) argued that, when there is a network shift, it is more likely to change from an informal arrangement to a more formal

176

B. Li et al.

arrangement. However, if a network has become an administrative organisation, deformalising it would be difficult. Networks can be formed via top-down or bottom-up forces (Provan & Lemaire, 2012). Top-down networks are formed through government-controlled funding to incentivise network participants, such as the situation with service procurement. This type of network is suitable when the network participants have weak ability to self-organise. It takes this network a longer time to cultivate the ability to coordinate. Therefore, the fund holders need to give space and time to the network members to build network trust and commitment. In contrast, when a network is formed through bottom-up initiatives, it must justify its need to exist. It also takes time to form a stable network.

10.5  Methodology 10.5.1  How to Analyse Network Transition Network transition can be analysed in different ways. As discussed earlier, network transition is about the process of Network A shifting to Network C.  Supposedly, Network A is the initial state of the network, while Network C is the desired stable network. At this point in our research, the network may or may not have reached Network C—it may be at point B at a given time. Thus, understanding network transition involves an effort to understand the relationship between Networks A and B, and B and C as follows: (1) In what ways is Network B different to Network A? (2) In what ways is Network B different to Network C? (3) Is Network B moving steadily toward Network C? What are the remaining barriers for Network B to reach Network C? Network transition is an ongoing process. Thus, we need to study a network at different time points to capture the dynamics of the network. To be realistic, for the purposes of this research, we visited each location once and studied the status of each network at that time in the research. As our fieldwork was undertaken via in-depth interviews and focus group discussions, we captured the issues at an earlier stage of the reform. After all, the reform was introduced not long ago. To produce research for a longer time span, we would need to undertake follow-up research in the future. To capture local varieties, we also undertook comparative analyses of communities in different cities. The reform was piloted in multiple locations, which offered good opportunity to undertake comparative studies. In the past, the social service system in China was designed so that it offered a similar structure throughout the country’s urban neighbourhoods. The past service delivery structure was a bureaucratic system that had a large base with many local bureaucratic networks.1 This relatively unified system  In this chapter, we treat the bureaucratic system as a type of formal network. This is because old age services, although limited in the past, always needed inter-professional or inter-sectoral collaboration. In this sense, if we examine these services at the local level, they are an extreme form of a formal network that is governed by a professional body (the higher authorities). 1

10  Social Organisations and Old Age Services in Urban Communities in China…

177

makes the study of China particularly informative, as we can determine the system variations in the older system, which significantly helped simplify the analyses.

10.5.2  How to Assess Network Stability As discussed earlier, the purpose of this research was to assess whether the old age service network in transition has stabilised and whether it can be sustained. A stable network in this research refers to the crucial features of the network remaining unchanged or at least being accepted by members of the network. Provan and Kenis (2008) argued that defining the nature of a network requires the network to be examined in terms of four characteristics: (1) trust, (2) scale, (3) goal congruity, and (4) the necessity to use the network to deliver tasks. They also used these features to determine different models of network governance. These are intuitive features that demonstrate the interdependence between network members. Provan and Kenis (2008) proposed three types of network governance and argued that they may shift from one type to another, but in a certain direction. The first type is a participant-governed network, which means that members of a network can assume joint responsibilities to govern the network. The second is a lead organisation-­ governed network, in which one core member is responsible for leading the network. All network activities and main decisions are made by the core member. The third is a network administrative organisation. This is a network governed by a relatively independent management organisation, such as a professional manager who does not work for any of the members. Provan and Kenis (2008) applied their four network characteristics to the three network types, and established the features of each type of network. They argued that a participant-governed network has a higher level of trust among its members. It usually has a smaller number of members, has a higher degree of goal congruousness, and can produce good performance when the tasks do not demand strong management capacity. Such a network has stronger internal legitimacy; however, its external legitimacy can be challenged. This type of network is flexible and more adaptable to changes. It is very suitable for performing individual tasks, rather than long-term stable tasks. In contrast, a lead organisation-governed network has lower trust between network participants. The number of network participants is not very large; however, there is a lower level of goal congruence. When the requirement for network coordination is not very demanding, this type of network can function effectively. This type of network has stronger legitimacy, both internally and externally, and decision-making is more effective and stable. Finally, a network administrative organisation has strong goal congruence. There are larger numbers of members than the other two types of networks, and this type of network requires a stronger capacity to run. This type of arrangement is more attractive when the organisation faces legitimacy challenges externally. The efficiency of decision-making is also better than in the co-governed networks. At the same time, it is more formal and more stable.

178

B. Li et al.

Provan and Kenis’s (2008) categorisation sheds light on the stability of networks. To examine network transition, we argue that the ‘scale’ of a network should not be used as an indicator of network stability. At most, it is an indicator of the difficulties encountered by the network in seeking to maintain stability. Therefore, it should be treated as a ‘risk’ factor. This line of theoretical development has several insights. Networks can be formal or informal. Informal networks may evolve and become more formalised over time; however, it is difficult for a formal network to be deformalised. Both top-down and bottom-up networks need time to stabilise. A successful network transition can only be accomplished when the new network is stabilised—that is, when the tasks it seeks to accomplish require network efforts, and there is a common goal and trust among the network members.

10.5.3  T  he Sub-research Questions for Analysing Old Age Services in China Following this logic, this research examines network transition based on aspects of the old age service reform in China. The following areas are considered: • The changing core members of old age service in China—this part of the analysis will examine who were the core members of China’s old age service during different historical periods • The state of the network in terms of membership, goal congruence and trust, as well as whether the new tasks really demand network actions (‘network-ness’)— this part of the analysis will allow us to determine whether a new network has been established • The outcomes of the network, whether there has been improvement in old age services, and whether the services are sustainable

10.5.4  Data Collection and Methods of Analysis This research is based on our fieldwork in Shanghai, Hangzhou in Zhejiang Province, Chengdu in Sichuan Province, Guiyang in Guizhou Province, Haicang in Fujian Province, and Taicang in Jiangsu Province. The data were collected during August 2014 and May 2016.2 The data used in this chapter came from the following sources: • Historical documents and official statistics: This type of information helped us trace the history of policy networks and enabled a better understanding of their  As agreed with the United Nations Research Institute for Social Development, we used some of the information gathered (from Shanghai and Chengdu) for an earlier project in order to offer more variety to the types of locations examined in this research. Our main report includes more detailed discussion of these six places and the criteria used to select them as the research sites. 2

10  Social Organisations and Old Age Services in Urban Communities in China…

179

status quo. To attain a broader picture at the national level, we used the CHARLS survey to perform background analyses. These data were analysed by members of our research team. We also used second-hand data reported in the national-­ level survey reports undertaken by government think tanks and relevant ministry research offices. The sources of these data are cited in full when used in this chapter. • First-hand data: We conducted interviews and focus group discussions with the commissioners of services for older people, including the Civil Affairs Office and Office of Ageing Affairs, and service provision organisations, including publicly- and privately funded care homes and day centres, community service platforms, community managers, NGOs, and volunteers. The interview schedules focused on finance, service delivery, and governance. We raised questions about network setup, stakeholder relationships (trust and agreement regarding the goals of the network), coordination, and network outcomes. During this fieldwork, we used mobile telephones, laptops, and notebooks to take notes. In most cases, we also kept a digital recording of the sessions. As all researchers could speak Chinese, we did not transcribe the data. The recording was used as a back-up for checking the missing details in the interviewers’ notes. • Network mapping: For the analyses, we performed network mapping based on the stages of reform and examined the changes in the networks over time. The mapping was undertaken at community level. In this manner, we were able to identify what had changed over time. We used the interviews to analyse the stakeholder relationship and assess the goal congruence, model of governance, and ‘network-ness’ of the networks.

10.5.5  Limitations of This Research The limitations of this research should be given due attention. The practice of NGOs providing services to older people in China is still at an early stage. The fieldwork was conducted in the cities that piloted the reform, which meant that they were ahead of other parts of the country in terms of adopting the reform; thus, the local governments were more committed to the reform. As a result, they were more open to suggestions and interactions with other members of the network. In this sense, the political will to implement the reform was not an issue, as in many other contexts. However, as this research did not aim to provide a comprehensive assessment of old age services across the country, but rather to understand the process of transition, we did not consider it inappropriate to only study the pilot cities. Instead, the focus was on the effects of SOs’ involvement on the existing service networks. Gathering information in the cities with an active service network meant that we could investigate a wider range of services and contact a larger number of network participants. Of course, we fully acknowledge that further research will be needed to enable a more representative sample once there is a national rollout of the services.

180

B. Li et al.

10.6  Research Findings 10.6.1  A Brief History of Network Transition Policies relating to older people’s services in China have travelled a long way during the last three decades—from limited recognition of the ageing population in the 1980s, to a focus on older people’s rights in the 1990s, to a deeper understanding of the relationships between population ageing and social services in the 2000s, to the formal inclusion of the ageing population as a vitally important issue in the government agenda in 2015. These policy changes are closely linked to the development of the social security system and adjustment to government functions in China. Meanwhile, the development of older people’s services can also be regarded a result of constant gaming between the government and market, and between the government and society to achieve equilibrium in resource allocation. In the following sections, we discuss the path of changes in China’s networks for old age care. We observe the changes at the level of an urban community, which is also used by the local government as a basic unit of administration. It is important to note that there have also been several changes in the unit of governance. However, what we try to examine in this report is the grassroots level of governance. This means that our research is at the intersection between public administration and self-governance. Usually, older individuals would have one public service provider in this community. However, individuals can have multiple providers to choose from in the private sector. The purpose of this section is to review the history of changes, while also providing an overview of the stakeholders in these networks.

10.6.2  Combining Family Care and State Support In 1954, the first edition of the Constitution of the People’s Republic of China stipulated that sick and disabled older people were entitled to receive financial support from the state and society. The main responsibilities of the state were to provide social security to retired people and implement the retirement system concerning state-owned enterprises, public institutions, and government organisations. The state provided subsistence to retired workers; however, for older people in general, family members were supposed to be the main providers of care. It was required that children should fulfil their duty of filial piety and not abuse their parents. After 1958, the traditional functions of family were criticised widely, and the people’s commune system started to take charge in both rural and urban areas. It was believed that women should not necessarily be the only care provider in the family. In addition, the work achievements of the members of the people’s commune were individually recorded (rather than pooled together), managed, and reallocated by the head of the family. This system was considered a major breakthrough from the traditional family model (Luo, 1959), which resulted in mass production, the

10  Social Organisations and Old Age Services in Urban Communities in China…

181

collectivisation of social life, and the socialisation of family work (Liu, 2006). Even though this system continued to emphasise that children should care for their parents, it was different to the traditional model of care provision. Since older people received a pension from their employers, they were largely economically independent. From the perspective of older people’s care, the state employers (also known as work units) provided various types of welfare services, such as health checks and healthcare. However, personal and domestic care was mainly the responsibility of children. The socialisation of old age care was very limited, and services were targeted at those who could not take care of themselves and had no children or relatives to care for them. The system in rural areas was further limited, targeting those older people who faced the ‘three no’s’ (no children, no income, and no relatives). By 1964, there were 700 care homes across the country serving 79,000 ‘three no’s’ older people (Pei, 2004). However, due to difficulties in management and lack of funding, this system stopped providing services after some time in many regions (Liu, 2006). Therefore, in the planning economy era, service provision by society was limited, and family members were the main providers of care. After the collapse of people’s communes and the implementation of economic reforms, many state-owned enterprises were either privatised or went bankrupt. Social services and the social security system in rural areas were weakened due to the shrinking of the collective economy. In this period, social welfare institutions for older people did not change significantly. Bian, Logan, and Bian (1998) observed that, at the beginning of the 1990s, the old age care model continued to be heavily hinged upon family care. This was in stark contrast to other areas of society, where the values of traditional society were seriously eroded. Their research suggested that the traditional family care model had been strengthened, rather than weakened, through intergenerational living arrangements (Fig. 10.3).

10.6.3  O  ld Age Care Service Network as a Response to State Enterprise Reform In the 1990s, the Chinese economy became more market oriented and globalised, resulting in further changes to the family and social structure in urban areas. This can be observed in several areas. First, younger generations had reduced ability to care for their older parents, especially as people became more mobile. As urbanisation and rural–urban migration intensified, the scale of housing demolition and relocation, and number of people seeking education and employment opportunities outside their hometowns increased. As a result, the number of older people not living with their children increased. Even for adults living with their parents, younger generations’ capacity to care for their parents declined due to increased work pressure and long working hours.

182

B. Li et al.

Fig. 10.3  Old age care service network before marketisation

Second, the average household size decreased from 4.41 in 1982 to 3.96 in 1990, and then to 3.44  in 2000. This was partly caused by the one-child policy, which drove down the fertility rates of young couples and consequently reduced the size of the extended family. It was also related to changing habits in people’s living arrangements. As a result of improved housing conditions, an increasing number of young couples chose not to live with their parents, and nuclear families became increasingly common. Third, the sense of community was eliminated. In the past, housing resources were distributed by state employers, and employees working for the same employer were geographically connected through this housing allocation institution. This was especially the case for large state enterprises, where employees were often living densely concentrated in certain areas or communities. In this case, widowed or single older people could receive help from an acquaintance network or from people from the same sub-district or same state employer. However, following the privatisation of housing resources, people’s mobility increased, and the unitisation of housing properties reduced the frequency of social contact among neighbours. At the same time, the mobility of the labour force continued to rise. This meant that social relationships among neighbours were no longer based on employment and long-term residence. As a result, a society that used to function through acquaintances was seriously undermined from multiple dimensions, and the sense of community formed under the state employer system started to break down. These changes posed a challenge to the traditional caring model, which relied heavily on the informal help provided by family members and neighbours. Further, from the perspective of income, many enterprises (especially those that could not make a profit) struggled to pay their employees’ pensions. This was due to the high mobility of employees, the increase in the number of retired employees, and enterprises going bankrupt and laying off employees.

10  Social Organisations and Old Age Services in Urban Communities in China…

183

The green boxes in Fig. 10.4 highlight the changes caused by the reform in this period, which are discussed as follows. The Chinese government built a social security system, which was a financing mechanism to accumulate pensions to protect people against the risks associated with old age. However, the social security system partially helped solve the problem of financing old age expenditure. The services that money could buy still heavily relied on the care provided by adult children and family members. The Marriage Law stipulated that adult children had the duty of providing financial support to their parents. If the children ignored this duty, any parents who were unable to work or had difficulties in their lives had the right to request financial support from their children. Meanwhile, the government gradually built the social insurance and minimum living allowance schemes, which incorporated individuals, enterprises, and the state into the social security financing system for older people. In 2011, the social security system for older people in urban areas was extended to rural–urban migrants and informal employees. Even though there was not yet a unified social security system for older people, the payment and entitlement systems among different groups of users were becoming more integrated. The combination of resident endowment insurance and enterprise endowment insurance facilitated the formation of an endowment system funded by multiple sources. Of course, the Chinese government was still tweaking the system, and its implementation encountered considerable difficulties (Li, 2014). Further, due to the problem of ‘empty pension accounts’, the pension funds have been in serious debt for years. Second, the types of care became diversified from the 1990s. The Rights Protection Law for Older People of the People’s Republic of China was enacted in

Fig. 10.4  Old age care network to cope with the consequences of state enterprise reform

184

B. Li et al.

October 1996. For the first time, this law proposed to gradually build service facilities and networks to meet the needs of older people and help them recover from diseases. A specific target was set in the Tenth Five-Year Outline Regarding the Development of Older People’s Affairs: ‘There should be 10 care home beds for every thousand older people, and care home services were to be provided in 90% of the rural towns and villages. The aim was to construct a community-based older people’s care system that provided comprehensive and multi-layered services with an effective monitoring mechanism and high-quality workforce for older people’s services’ (State Council, 2001). Even during the central planning period, the old age service system in China was not a hierarchical system in the strict sense, as the tasks to be fulfilled unavoidably required multiple stakeholders’ collaboration and horizontal coordination. Therefore, the Chinese government system had been portrayed as a matrix system (Lieberthal, 1995; Liu et al., 2015). In this system, the local governments were part of the bargaining process, rather than being followers of higher level commands (Zhong, 2003, 2015). However, the local governments did respond to incentives introduced at the higher level (Li et al., 2015). Due to the complexity of old age services, they have always been the product of multiple government agencies’ bargaining. As shown in Fig. 10.4, several government departments were needed to approve each project, and even more when private services were introduced. This is why a coordinating agency—the Old Age Affairs Commission (‘Laolingwei’, or Older People’s Association, ‘Laonian Xiehui’)—was introduced in 1999. The members came from 32 government ministries and offices, and the purpose was to plan and coordinate to implement policies related to older people’s affairs. The commission also had local branches (the Old Age Affairs Office), which functioned in a similar manner to the commission at the central level. Although there was no significant change to the service system in this period, it was observed that some urban communities started to bring female carers in groups from rural villages to cities to complete paid housework in the Jiangsu and Zhejiang provinces (OXFAM, 2014). As the number of rural–urban migrants continued to increase, a private housework market came into existence. The average level of wages for migrants was much lower than that in the cities during this period. Workers were paid hourly or monthly for their housework. These workers not only helped older people with their housework, but also relieved the working adults if the caring responsibilities, which filled the gap in older people’s services. By the mid-­ 1990s, paid housework had spread across the country.

10.6.4  C  ombing the Government, Family, and Market in the Caring System (2000–2010) After 2000, the average household size continued to decline to reach 3.1 in 2010. This resulted in an increased responsibility to care for older people in the family. After the institutional barriers that separated the labour markets were removed, it

10  Social Organisations and Old Age Services in Urban Communities in China…

185

became more common that older people lived far away from their adult children (Li & Shin, 2013). Meanwhile, as the life expectancy of older people increased, a larger number of older people suffered from ageing-related chronic diseases, physical disability, and cognitive impairment. Adult children were not always able to care for their parents due to geographical distance and lack of expertise, even though they wished to do so. As a consequence, informal care struggled to cope, and there was mounting demand for professional and accessible care and services for older people (Zhang & Goza, 2006; Hesketh, Lu, & Xing, 2005; Flaherty et al., 2007). In the 11th Five-Year Plan period, which started in 2006, more financial resources were directed to social insurance. The government proposed to build the older people’s service networks based on a combination of family-based care and the socialisation of care. They also proposed to foster a market that sold products to older people to meet their special needs. Since 2008, home-based care has become more common in urban communities. The idea of the reform in this period was to form a home-based care service network that was led by the government, incorporated different social groups, took a variety of formats, and covered a wider range of services. In its 12th Five-Year Plan, the government further proposed to build an old age care system that was based on home care, dependent on the community and supported by care homes. They stipulated that there should be 30 care home beds per 1000 older people. National standards for care facilities at the community level were established (Wang & Xie, 2013, pp. 156–157). In 2012, the Chinese government published the Revised Version of Older People’s Rights Protection Law, where the basis of old age care shifted from family support to home-based care. However, they stipulated that family members should provide care for older people. The responsibilities of the government were unclear, but the government stressed that the state would ‘make all-round informal care policies, encourage family members to live with or live near older people, create opportunities for older people to let them migrate with their spouse or family carers, and provide support to family carers’. From the perspective of legislation, these stipulations were all but general principles. They did not touch upon the specific responsibilities assumed by the state (Zhang, 2014, p. 41); however, the 12th Five-Year Plan did establish clear policy objectives to implement. At the community level, this period witnessed the introduction of community service space. This meant that communities not only had administrative space, but also had a service centre that could be used to provide social services to residents, including older people. The space could be indoors—where daycare centres, food halls, and playrooms were located—or an open space in which older people could socialise and exercise. The corresponding services were provided by local governments or private businesses (Fig. 10.5).

186

B. Li et al.

Fig. 10.5  Old age care service network with private market options

10.6.5  SOs as Service Providers in the Community From 2000, privately funded care homes started to gain popularity. Older people, including healthy people, were attracted to the idea that they could socialise with other people in care homes. In addition, a large number of enterprises went bankrupt. As a result, some older people who had just passed the retirement age and some who were much younger than retirement age stopped working. They were physically healthy, but did not have much to occupy them after retirement. Private care homes identified this niche and targeted able-bodied older people. However, the disadvantages of institution-based care soon became clear. Older people found it inconvenient to live in care homes because it was not easy for their adult children to visit, and it was not as relaxed to share other facilities with other people. As a result, some able-bodied older people moved back to their own homes. There clearly remain gaps in the old age service system, with the system suffering from a serious shortage of services. For example, there is a growing demand from older people dependent on long-term care and medical care and their children to have access to institutionalised care. These could be long-term, temporary, or occasional services, provided as residential or daycare services. Although family care and institution-based care are in different settings, they still belong to the same sphere of ‘care’, in which older people are perceived to be vulnerable and needing help. For older people who have lost the ability to lead an active life, either temporarily or permanently, this type of care is necessary. However, the spectrum of

187

10  Social Organisations and Old Age Services in Urban Communities in China…

services required by older people goes far beyond care, and older people are also lacking facilities and services that are outside the care system. For example, there is demand for a new sphere of infrastructure and services, such as localised and adaptable services, and public infrastructure that is suitable for streamlining and removing the barriers (both psychological and physical barriers) to enable older people to navigate their indoor and outdoor activities; public and private life; and family, kinship, and other socialising activities. Thus far, the state, market, and home-based care cannot offer sufficient alternatives. In this sense, the introduction of SOs is expected to be able to fill this gap. These organisations may not only be able to bring in new resources, but could also supplement the delivery of existing services, establish new services, and provide new infrastructure to enable service delivery. Figure 10.6 shows the ideal model of the network in the future. The most obvious change in the network structure during this period is the role of community service centres. In the past, these centres were one of the service providers in the community. After the reform, they changed into a platform to link resources, users, and service providers. At the community level, they specialised in coordinating network members. With the help of new technology, community service centres could also function as internet and call centres to enhance the ‘matching’ capacity of community service centres. In this sense, a good community service centre could become a grassroots network coordinator that reduces the difficulty of coordinating the tasks of the Old Age Affairs Office. Thus, SOs could assume service delivery together with private providers. In addition, the staff members in the community service Venues and services

Service providers

Venue providers

Funders

Family carers (spouses and children) Family carers (spouses and children)

Family care

Domestic help (individuals or companies)

Privately owned care homes

Private enterp enterprises r rises

Individuals

Social Insurance Employers

Private investors

Publicly owned care homes

Bureau of Finance

Community service centre

SOs

Bureau of Constru ction

Bureau of Civil Affairs

Bureau of Planning

Day centres Bureau of Health

Health care

Charities and foundations f undations fo (social organisations)

Fig. 10.6  Old age care service network with SOs—the ideal model

Coordinator: Coordinator: Old Old Age Age Affairs Affairs Office Office

188

B. Li et al.

centre are not only responsible to local governments, as in the past. They also report to other fund holders, such as private investors and charitable organisations, and are responsible to users. However, while this is the ideal scenario, networks are still in transition, with communities at different stages in this transition. In the following section of this chapter, we examine the state of transition and the barriers that existing networks have to overcome to reach the ideal state.

10.7  State of Network Transition By examining China’s history, we can observe a gradual transition from a state-­ family care system (in which the state and families are the only fund holders and caregivers) to an increasingly diverse system of service funding and provision. As a result, compared to the old bureaucratic-style network in which all activities were formalised and contracted, there are more actors and less tight connections between the network members. However, it is difficult to determine whether earlier reforms were a success (such as the introduction of private providers), as the demand for further reform and introducing more actors could mean that the state-market-family solution was not sufficient or sustainable. An examination of the development of the older people’s services system in the three cities indicates that the objectives, characteristics, and models of networks underwent significant changes.

10.7.1  Goal Congruency At the time of this research, had the stakeholders reached agreement regarding the goals of the networks? The answer depends on the specific goals under discussion. Overall Support for SOs’ Involvement in Community Old Age Service There is an overall supportive attitude for the initiative to provide more services and more diverse services for older people in communities. In the pre-reform era, China was characterised as a strong government, weak market, and weak society. Since the implementation of economic reforms and opening-up policies, the market economy has transformed China into a ‘strong government, strong market and weak society’ model (Li, 2013). In order to strengthen society building, the central government decided to help not-for-profit organisations develop, empower the third sector, and ultimately establish a system with an effective government, orderly market, and active society. Incorporating SOs into the social services system was part of this agenda. SOs are expected to perform several functions. They should mobilise resources from different sources to achieve self-governance and self-service at the community level. In this manner, SOs may help transform the functions of the

10  Social Organisations and Old Age Services in Urban Communities in China…

189

government. Further, SOs may function as the agency of civil society. As a result, reformers at central government level expect SOs to nurture civil society and improve government operation. Our interviews indicated a strong awareness of these goals among the supply side. This was because the local governments viewed the introduction of SOs for community services as a top-driven initiative that had to be fulfilled, and training courses were provided to officials at all different levels. As discussed earlier, the neighbourhoods we visited were often communities that were considered keen to outperform other communities at this stage; thus, they were generally active in promoting this concept to their staff members. Service providers were generally enthusiastic about what the government initiatives aimed to achieve and were supportive of the overall initiative to develop old age services based in urban communities. Service providers comprise several types as follows: (1) Some were originally government-funded service providers, such as public care homes. In the cities we visited, the government-funded care homes were changed into SOs that continued to receive funding from the local government. Their staff members used to be public servants, but were no longer part of the government system. However, the services were largely unchanged and provided long-term care for the terminally ill. Depending on whether the government required them to be fully or partially self-­ sufficient, some began to operate like private businesses. In addition to serving senior civil servants, some of the facilities had also opened up to the fee-paying general public. (2) Newly established NGOs and social enterprises were trying hard to establish their services in communities. They received some funding from communities or local governments; however, this was mostly in-kind support, such as office space, workshop space, or some cash contributions. (3) Private sector providers were well established in the service sector, but also considered it an opportunity to be engaged with the trend of community service development. They viewed the thriving community services as having the potential to inspire demand for more of their services as well. Competition Between Government Employees and SO Social Workers In urban neighbourhoods, community resident committees (‘juweihui’) were composed of government-appointed officials and social workers. Officially, these committees were introduced in the 1950s to facilitate community self-governance. Over time, they became government agencies to perform government-assigned responsibilities and were funded by the higher authorities. As a result, they were viewed as branches of the local government (Liu, 2013). When some governments began to experiment with introducing social workers to improve community self-­governance, staff members of resident committees perceived a threat to their authority in the community, and conflicts become unavoidable. The following issues arose as a result: 1. Community leaders wanted to turn SO social workers into their own staff members. As a community leader in Taicang reported, ‘The new social workers did a

190

B. Li et al.

good job here. I learnt a lot from them. They also helped me to do a lot of work. However, they should become part of our organisation and work for us’. The SO staff members’ intention to operate independently and work for different communities resulted in tension with community leaders. Ultimately, the community leader decided to charge higher rent in the hope of coercing the SO to become part of the resident committee. 2. Community leaders wished to compete with the SOs. In almost every community, we interviewed, the same issue was raised repeatedly: what is the labour division between residential committees, the associated service centres, and the SOs? The tension was particularly strong between community centre staff and SOs working to improve the community atmosphere by organising social events. As one officer stated: Social workers from SOs worked differently from us in the past. We agree that they had introduced better working approaches to the communities. But we also noticed that these approaches are not that difficult to learn. Our staff members have now gained good understanding of how they work. Now we can combine their approach with our own strength in local knowledge and in our ability to mobilise resources much more effectively … Therefore, in the future, either they have to work for us, or we just train our own staff members to be social workers. As they are our own staff members, we do not need to pay extra money for extra tasks. It is more efficient for us.

In this community, there were several rooms in the community service centre that were not used in the past. The community leaders agreed to spend some money to hire two professional social workers from an organisation specialised in improving community participation. As the social workers took over, they actively engaged with the residents and established self-organised social groups and workshops. A whole range of events and services were established, such as cake baking, dancing, yoga, game rooms, and meeting rooms. The community leader was initially happy to see these changes and invested money to subsidise the equipment needed for the training courses. However, she soon learnt the practices of the social workers, and subsequently wished to replace them with the existing staff members in the community. However, the two social workers considered this to be only the first step of their service. Meanwhile, the community leader had already sent her staff members to take training courses for social work. According to the social workers from the NGO, the government officials did not understand the importance of independent social work, and believed they could perform these services equally well. 3. Community leaders were yet convinced by social workers who try to work in the communities. As a community leader in Haicang reported: We had worked here for many years and we understand the people here. We may not be as well educated as these youngsters [social workers sent by social work NGOs to the community], but we can speak the language of the locals—not only the local dialect, but also the cultural language. When we do interviews, we visit the interviewee’s home and asked to have lunch with them. The interviewees would be happy to cook for you and we did the interview when eating their food. They would tell us everything. When the social workers do an interview, they offered to pay for the interviewee’s time. The interviewee felt insulted by the offer to pay, which was not even a lot.

10  Social Organisations and Old Age Services in Urban Communities in China…

191

These comments show that the difficulties faced by some SOs need to be interpreted more carefully. They may not always involve politically charged state–society confrontations, but rather a process of renegotiating territories. It is possible that some community leaders felt that NGOs threatened their authority or even their jobs in the community. They responded by trying to internalise the SOs, imitate the SOs’ practices, or improve the SOs’ practices. In this sense, SOs have indeed motivated the establishment to be more responsive to social needs. Different Understandings of the Roles of Government Sponsorship There seem to be clearly different understandings of the roles between different levels of governments, and between governments and NGOs. As aforementioned, the purpose of the reform issued by the central government was to encourage SOs to be more involved in service provision and contribute additional resources to the services in order to better satisfy the needs of older people. However, local governments could interpret this differently. The government in Hangzhou focused its attention on service efficiency. It strictly controlled staffing costs, while the number of care homes kept increasing. This led to insufficient staffing, even in state-funded care homes with very good facilities. The quality of services fell short of older people’s expectations; thus, the government-owned care homes had a very low occupancy rate. The largest care home in Hangzhou, which opened in September 2014, was no exception. The No. 3 Welfare Institute had 2000 beds for older people. Before it was officially opened, more than 4000 people came to register, and the institute had to selectively choose the 2000 people to live in the facility. However, after 1 year, only 290 people still lived in the institute. The price was considered a main issue, with the following costs incurred for accommodation: • • • • •

nursing room (about 42 m2): 1100 yuan/month standard room (about 33 m2, shared by two people): 1500 yuan/month small single room (28 m2): 2700 yuan/month large single room (33 m2): 3250 yuan/month on suite for singles or couples: 4100–7500 yuan/month.

This price did not include care services. The costs of care for people who could live independently were 430, 530, or 630 yuan/month, depending on the level of care needed. The costs of care for people with special needs ranged from 830 to 2230 yuan/month. However, in cities like Hangzhou, there may be a high people who could afford these prices. As reported by some people, in care homes run by private investors and NGOs, the facilities and living conditions may not be as good, but the prices were similar. This means that there must have been other reasons for the institute’s low occupancy rate. As reported by the media, older people are often worried about the quality of care workers. In most care homes, workers have not received professional training to become care workers. Further, professionally trained care workers would

192

B. Li et al.

not want to work in public or government-subsidised care homes, as the salaries are much lower than the market rates for private carers and childcare nurses. Another issue raised in all communities in the cities studied was the different understandings of local governments’ roles in the development of SOs. In the state– SO partnership structure, the government contributed in-kind, such as by providing venues, and in cash, such as by providing initial start-up grants and annual cash input. Staff costs were rarely paid by the government. Even when the government purchased services directly from non-profit organisations, the government paid the minimum wage to the staff members, which was much lower than the wage paid to the professionals working for privately funded organisations. The government officials interviewed considered this partial funding model an incentive mechanism, as they did not wish SOs to become dependent on the government for too long. The purpose of the support was to help SOs begin their businesses, and SOs were expected to graduate out of this stage and become independent. Therefore, even at the early stage, the government adopted an incentive strategy by not fully funding the services. To receive government funds, SOs were expected to seek alternative funds to match the government support. However, many SOs had a very different understanding. They perceived their services to be beneficial to the society and expected the government to be their main source of finance. Therefore, we heard repeated complaints about the shortage of government funding. Even internationally, it is known that state-supported NGOs often face the challenges of insufficient funding (Antrobus, 1987). However, in the context in China, the debate was about the perceptions of the state–NGO–market relationship. The government provided funding with the idea of establishing a mixed welfare system, in which the state was only a partial funding provider, whereas the SOs wished to become contractors of fully funded government services. The misunderstanding between the government and SOs was raised when we conducted a focus group with district officials and SOs. One SO wished to establish an activity centre in a community. The community provided a room, yet the SO leader needed another 100,000  yuan to refurbish and furnish the room. The government was reluctant to provide these funds; thus, the project did not move forward for a while. The manager of the SO was frustrated about the perceived lack of sincerity from the local government. However, the government officials involved believed that 100,000 yuan should be a lot of support, and the SO should be able to obtain extra resources or provide fee-based services to ‘earn’ their way. However, as we observed in quite a few community-based services run by SOs, the SOs would rather wait for the government to provide funding than provide fee-based services, as the SOs considered themselves non-profit organisations. This was a sign of a frequent misunderstanding about the meaning of ‘non-profit’. Even in Shanghai, where SOs are highly active, our interviews showed that, even though some SOs were under huge financial pressure, they still cherished the idea that the government might change its mind in the future. For this reason, they generally had a ‘wait and see’ attitude, which prevented the SOs from seizing other opportunities. There are also debates about this issue in academic circles. One line of argument suggests that the state should provide full funding, especially if the government was

10  Social Organisations and Old Age Services in Urban Communities in China…

193

the original provider of a project. This argument is based on the fact that the government continues to collect tax. Withdrawing from social services means that the government should spend at least the same amount of revenues on the services provided by NGOs (Xiong, 2014). As noted in our research from multiple cities, it would not be realistic to ask the government to provide full funding for all SOs, simply because there are many new services and organisations that did not exist in the past. Moreover, if SOs are all funded by the state, they would be unavoidably constrained by government budgeting exercises, which is likely to further deprive SOs of their autonomy. The government’s intention to use seed funds to leverage private and charity funds is a more viable practice in the longer term. However, greater efforts need to be devoted to provide more structured training and better communication with SOs in the early stage of the funding cycle—it is important to help them establish appropriate expectations.

10.7.2  Trust Despite the initial enthusiasm for SOs to offer age care services, the lack of trust between various stakeholders arose as an issue that will require time to overcome. Lack of Trust Between Government Officials and NGOs Despite the overall support for the goal to improve services, not all stakeholders shared the same goals in their daily operation or for each project. For example, superficially, the local governments could relinquish responsibility as they contracted out service delivery. However, this meant goal and role changes. In the past, local officials did not have to distribute money to SOs—they simply allocated funds to other government agencies according to the budget, which was a relatively simple task. Now the government officials, who were inexperienced in working with SOs in the past, were required to behave like venture capitalists. They had to select projects operated by people with whom they had not previously worked. In addition, government officials were held accountable to their managers to perform well—in this case, ensuring that the SOs they had supported or contracted would deliver better outcomes than in the past. Thus, they were keen to avoid being perceived as bad decision-makers. As our study revealed, after distributing the funds, the officials became restless. They began to worry whether the SOs would deliver what they had promised. As a result, some officials strove to keep SOs’ activities under their control. For example, in Guiyang, one community leader visited the social entrepreneurs every day and questioned the young entrepreneurs who she supported about why they spent so much time in the office, rather than visiting their prospective customers. In another case, the official interviewed said: I had never worked with NGOs in the past. The higher up [shangbian] gave so much money to us and we had to spend them. But there were not many people that I could trust to give

194

B. Li et al.

the money to. After giving eight million to [A], I have to make sure that we can see some results. Otherwise … the government is now operating heavily in anti-corruption campaign. I do not want to be viewed suspiciously by others.

In Taicang, the local government created strict rules for the NGOs—particularly those operated by people from outside the province, and those offering new services to claim the costs after they had delivered services. To do this, the NGOs had to provide detailed financial reports on a daily basis. In a fiery exchange between an NGO leader and a local official during our interview, the NGO leader complained: We indeed received money from you, but I have to hire an extra staff member to write up what we have done every day and collect all the receipts every day in order to get the money. It is time consuming and suffocating … You request us to report everything and show the results. However, not all the impacts of our activities can be observed directly in a short time and some are not even measureable. For example, our work made older people a lot more active and happier in the community. But on your accounting system, we only organised an event, which can be organised by any private event masters more cheaply, as some of your staff suggested. But the purpose of our event is different. The improved community atmosphere is not counted in your reporting system.

Our findings challenge some of the existing literature that has used the resistance framework to analyse the relationship between the state and NGOs (Spires, 2011). These studies perceive the local governments as tools by the Communist Party to control non-government activities and prevent the development of civil society. This theory was good at predicting the behaviour of previous state–NGO relationships, as NGOs were indeed considered troublemakers by the regime and were placed under tight control (Stern & O’Brien, 2012). Further, this theory may still be useful in explaining the relationship in some contexts, such as in regard to workers’ rights (He & Huang, 2015). However, in the field of old age services, the relationship between the state and civil society has been transformed in several ways as follows: • Local government officials are entrepreneurs (as some observers accurately depicted)—the introduction of SOs has turned local officials into venture capitalists, which means that they are fund holders who select projects or organisations in which to invest, and expect to receive returns in either social and economic terms. • NGOs are not viewed as activists who try to change the system, but as potential supplements to government services. SOs are often portrayed as a way for local governments to distance themselves from service provision. It is also important to highlight that contracting suitable projects to SOs can help enhance the legitimacy of the government, rather than undermining it. In this sense, local governments have an interest in nurturing such organisations. In this sense, the control that the government retains overs SOs could be a matter of transition and establishing trust in the process of transition, rather than deliberate sabotage of the NGOs’ work. The experience with some NGOs in Haicang in Xiamen City evidences this relationship. Some NGOs found it difficult to attract customers; thus, after they had received funding from the local Bureau of Civil Affairs, the official in charge used his network to help his NGOs gain access to

10  Social Organisations and Old Age Services in Urban Communities in China…

195

customers. As a result, the higher officials viewed his record favourably, and the NGOs were more easily able to attain success. This is a sign that local officials do have motivations to support NGOs. However, at the individual level, some local officials are not as entrepreneurial, and have resorted to financial control or inspection to direct, rather than facilitate. This type of control should be differentiated from the political control that earlier research has indicated. Lack of Trust Between Users and SOs Users do not trust SOs’ services—the legacy of the ‘strong government, strong market and weak society’ is difficult to change quickly. In the past, when social services were prescribed by the government, people did not have great expectations of what they could gain from these services; however, they did have high expectations of the quality of services on offer. This was partly because the old age care services provided by the public sector targeted urban elites, providing services to which higher ranking government officials or military retirees were entitled. For ordinary people, staying at home was the only option. When local residents were invited to community-based facilities—which appeared to be less formal, smaller, cheaper to access, and without a track record for good services—prospective users were reluctant to access the services, especially if the targeted users were older people. As a result, initially, new SOs found it difficult to attract customers, even with the government subsidies. This was particularly problematic for domestic services (Huang, Zhang, & Li, 2007). Another trust issue was raised by community leaders in resettlement communities, where residents were mostly older people from rural areas. These older people did not have experience living in urban communities and were less well educated than the urban older people. Social workers from NGOs were often young university graduates who were equipped with theories and jargon, or trained in other provinces where the local culture was different. These social workers found it particularly difficult to gain the trust of ex-farmers, who guarded themselves against people from outside the community. They were not keen to be cared for by these young people whose language was not practical or humble, who had different accents, who shared little life experiences, and who were sometimes overly sympathetic. This does not mean that the relationship between different parties in the network will remain unchanged. The activity-based SOs and day centres are becoming more experienced in service provision, and many older people using community-based services have increased trust in these professional services for older people, as well as increased demand for the more specialised services provided by SOs. In the course of completing the fieldwork for this project, some older people using community day centres expressed their desire to move into care homes in the future.

196

B. Li et al.

10.7.3  Network Tasks (‘Network-Ness’) One important debate in network analyses is whether we can call any multiple stakeholder system a ‘network’. This is why researchers are reluctant to consider a bureaucratic system a network. The ‘network-ness’ or tasks a service system needs to fulfil are not necessarily qualified as ‘network’ tasks if they involve a strict hierarchical system in which all network members work according to instructions from their headquarters. As Provan, Kenis, and Human (2008) suggested: ‘[Network] members not only recognize and accept their involvement but also work toward accomplishing both their own goals and those of the entire network’. It is not difficult to identify some level of network-ness in China’s old age services. As discussed earlier, the community service centres and Old Age Affair Offices were coordinating the stakeholders. The biggest challenge for urban communities when trying to provide old age services is having a workspace for these services. Urban neighbourhoods—especially those in central locations, with higher population density and old buildings—found it very difficult to gain planning permission to construct new buildings or acquire rooms in established communities. Within the community network, a community service platform is coordinated and monitored by specialist agencies. Above the community level, the network is organised by the government, and jointly governed by all participants. However, every government department has its own priorities, and thus cannot devote all its resources to services for older people. The fieldwork in Shanghai indicated that it is more difficult to locate a place to provide services in the city centre. Even though one department of the government is willing to approve an SO to provide services for older people, another department may have no quota of land to allocate to this organisation. If the departments offload responsibilities onto each other, SOs may end up having no land resources on which to operate. There are up to 20 participants at this level of the network, and Provan and Kenis (2008) stated that when the number of members in a network is greater than 20, it is very difficult to align their objectives. In this case, a dominant agency or agency specialising in governance is needed to ensure effective decision-making and network stability. At the moment, in China, the Office for Ageing Affairs is in charge of coordination at the local level. However, they are neither an administrative institution nor a main service provider; thus, they are not particularly strong in negotiation. It remains unclear whether China’s old age services’ network-ness is strong enough to be sustained. There certainly have been difficulties. The director of the Old Age Affairs Office (OAAO) in a district in Shanghai stated that the office did not enjoy the same level of power in different communities, which was influenced by the governing culture of each community. Sometimes stakeholders face unnegotiable constraints. Some old age care services in central locations needed to secure planning permission for construction. However, even if the SO secured financial support, the project could still be placed on hold because the Environment Bureau could not allocate quota for building on green space, or the residents were opposed to the service (this was particularly a problem for long-term care services

10  Social Organisations and Old Age Services in Urban Communities in China…

197

for the terminally ill, as it is considered unlucky to have such a facility in the community). The OAAO officer stated: We are the coordinator, but we do not have enforcement power. We can only try to persuade everybody. If they do not listen to us, we can do nothing. When it is about environmental constraint, nothing can be done, as it is the top priority of the central government.

10.8  Outcomes of Network Shift As the reform has progressed, old age services in China have witnessed significant change. Since the 1990s, the government has encouraged the expansion of care homes established by social forces. Pilot schemes for community-based care for older people were launched in 2001. Under the Starlight Program, 32,000 old age care facilities were established at the community level over 3 years. These facilities provided a range of services, including home help, emergency aid, daycare, health and recovery, and sports and entertaining activities. Meanwhile, privately funded care services for older people were also available. By 2005, there were, on average, 1.3 urban welfare facilities for older people in every sub-district, and every 9.8 resident committees had one urban welfare facility for older people across the country (Whitepaper Book of Development of Ageing Affairs in China, 2006). The changes in this period reflected the Chinese government’s intention to fill the gap in care demand after the collapse of the state employer system. The priority was to increase the capacity of community-based social services and shift the focus of the entire care provision system from the state employer to the market and community. However, unfortunately, the Starlight Program was considered a failure (Feng et al., 2012), as the services were beyond the reach of the majority of older people (Pei, 2009). Since 2006, the government has promoted the development of SOs as the providers of social services, and has launched a pilot scheme in 13 cities. SOs have subsequently played an active role in community-based services for older people, and have facilitated the development of the sector. According to the Ministry of Civil Affairs, by the end of 2013: there were in total 42,475 old age facilities and 4.9 million beds, an increase of 18.9% compared to the last year. There were 24.4 beds per thousand older people, an increase of 13.9% compared to the last year. There were 641 thousand beds in the care facilities and day care centres,3 an increase of 5.5% compared to the last year.

By the end of 2014, China’s total number of various types of pension services and facilities reached 94,110, with 5.778 million beds. The number of beds per 1000 older people was 27.2—an increase of 11.5% from the previous year (Ministry of Civil Affairs, 2015). Across the country, there were 2571 public institutions (or  The Chinese old age care services have several types of ‘beds’: hospital beds, residential home beds, community residential care beds, and daycare centre beds. In daycare centres, ‘beds’ refer to facilities where older people can rest during the day. 3

198

B. Li et al.

public sector organisations) serving older people, 21,000 legal aid centres, 78,000 rights protection organisations, 54,000 schools teaching 6.9 million older people, and 0.36 million elderly activity centres (Ministry of Civil Affairs, 2013). By the end of 2015, the total number of old age care services reached 116,000— 23.4% more than the previous year. Of these, 28,000 were registered old age care institutions and 26,000 were community-based old age service organisations and facilities. There were 62,000 facilities offering reciprocal support, and 6.73 million beds, among which 2.98 million were based in communities (including community care homes and daycare centres) (Ministry of Civil Affairs, 2016). In addition to care services, new type of services also boomed. By the end of 2015, there were 2280 national-level old age service NGOs, 210,000 legal aid centres for older people, 71,000 coordination organisations for protecting older people’s rights, 53,000 older people’s schools with 7.33 million older students, and 371,000 activity rooms (Ministry of Civil Affairs, 2016). All these figures indicate the dynamics of shift from a government provision model to a mixed model, with the market, SOs and home care as providers, and a combination of both government and market procurement. In this process, the government stepped back from its role as a service provider, and let the SOs or private sector take over service provision. Locally, network performance varies greatly. We categorise our six examined cities in two groups to report our findings. The first group comprises Shanghai, Hangzhou, and Chengdu—cities more experienced in working with SOs, even though Hangzhou and Chengdu began this engagement later than Shanghai. The second group comprises Xiamen, Taicang, and Guiyang—cities that have started SO development relatively recently.

10.8.1  Shanghai, Hangzhou, and Chengdu These three cities encountered a number of changes due to SO development as follows. First, the government’s roles changed. Networks used to be governed by the higher authorities. However, gradually, the management of service delivery was assumed by professional organisations, such as service quality monitoring bodies or community service centres. Some monitoring functions assumed by the government in the past started to be assumed by SOs, such as sectoral associations. For example, since 2003, the Shanghai Social Welfare Association has managed the association members. Members were expected to produce self-regulating rules and be evaluated by the association. Of course, the government continued to manage areas such as making long-term plans, formulating policies and standards, and approving applications. Second, the government clearly stood back from service provision and became service procurers. A variety of partnership models emerged, such as ‘public building and private/SO operating’ (‘gongjian minying’), ‘public-subsidising and private/SO operating’ (‘gongzhu minying’), assignment of lease, private/SO–public partnership, co-investment and entrusted operation. In these models, SOs and private businesses provided services to users.

10  Social Organisations and Old Age Services in Urban Communities in China…

199

Third, the government was no longer the sole fund holder. The partnerships mentioned earlier reflected the diversification of funding sources. Old age services could be funded by the lottery fund, charity donations, private investment, and in-kind contributions (such as volunteer services). Fourth, the service coverage of the networks varied by services, and new services were often better targeted. The government service volume and coverage were set according to the size or density of the population. The government defined the administrative boundary of a community and stipulated the types of services for every 10,000 people. This planning model created a set of standardised and uniformed services. For this model to operate, there is a condition—services must reach users economically and effectively. If this is true, the government could provide the same services within each catchment area. However, SOs were different to the government. They would rarely be as large as the government system and, as smaller businesses, need a sufficient catchment area, which could be different to the administratively defined government catchment area. A case in point is the community canteen. At first, it was fairly challenging for one organisation to deliver meals to the same group of older people in a certain community. To ensure that the menu was not too repetitive, the canteen had to change its menu every day of the week, and rotate the menus each week. At the beginning, older people were happy with the services; however, they soon were tired of the same rotations and asked the canteen to change their menus more frequently. Why do people rarely complain about the repetitiveness of dishes sold in the market, but complain about the canteens? The difference is that the service users went to the same canteen every day, whereas restaurant customers can choose from different restaurants. Canteen users had no choice but to access one service provider, and thus asked it to diversify its services. This posed a challenge to this SO, whose users were a fixed group of people. This issue also arose among the scheduled activities for older people in day centres. Day centres in communities were popular at the beginning, but lost customers over time, even if the service quality remained the same. Some services even became unused. However, from the service providers’ perspective, providing standardised services had lower requirements for staff training and facilities, which reduced costs. Diversified services were not only more expensive, but also more difficult in operation and management. In the face of these challenges, two solutions emerged in the communities we researched. The first was to expand the service coverage through inter-community cooperation. For example, meal services were jointly provided by several communities within the same sub-district. In Shanghai, older people were given vouchers so they could go to different canteens in the sub-district. In this case, even though the canteens did not change their menus frequently, older people were still able to enjoy varied menus by visiting different canteens. Similarly, older people in Chengdu were entitled to participate in activities in a day centre located in another community. Such arrangements also helped make better use of community space. Service providers that joined their operations were usually branches of the same SO, and redrawing the boundary improved the economy of scale. Service providers not affiliated with the same SOs might not be willing to cooperate with each other

200

B. Li et al.

because joint operation also meant the risk of losing customers through competition. Further, this also made funding allocation by the government more complicated, as there was not yet efficient coordination for funding usage between communities. Thus, the second solution was to subsidise some privately funded services. For example, restaurants that were geographically close to a neighbourhood were subsidised for providing meals to older people, or older people could eat in these restaurants with vouchers. This was a win–win situation, as older people had more meal choices, and catering services had more customers. Fifth, the service networks became increasingly multi-layered. Above the community level, some networks started to emerge: • Local government departments formed a policy network for stimulating old age services. This network focused on making policies. In a city, as many as 20 departments could be relevant to old age services within a local government. The OAAO, which was affiliated with the Bureau of Civil Affairs, had been the main coordinating organisation. Other organisations all established their own plans on old age services. For example: –– The Bureau of Civil Affairs—community services for older people –– The Bureau of Health—geriatric and palliative care services through its hospital systems –– The Bureau of Education—universities for older people –– The Bureau of Transportation—offers a discounted rate on travel fares for older people –– The Bureau of Finance—budget planning (in consultation with departments) and funding allocation –– The Bureau of Construction and Bureau of Land Planning—building infrastructure –– The Bureau of Commerce and Business—registration –– The Bureau of Accounting—financial monitoring. • A new specialised quality control network assessed, monitored, and controlled the quality of services delivered by NGOs. In the quality control network, local governments established professional evaluation standards, and purchased evaluation services from independent organisations. The providers’ performance could be assessed through expert inspection and user satisfaction tests. In some cases, an ISO quality control system was introduced to help service providers maintain the standard of services. Local governments contracted the work of the quality control system, but the member organisations were not dependent on each other and had clear division of labour. Hangzhou and Chengdu started introducing SO services later than Shanghai. Despite this, SOs were swiftly promoted by the local governments, and the services in these two cities were similar to those provided in Shanghai. However, some differences were evident. The Shanghai government played an important role in promoting and supporting SOs. For example, new social entrepreneurs could enter government-established incubators to enjoy cheaper office space, receive training,

10  Social Organisations and Old Age Services in Urban Communities in China…

201

and build a social network. Thus, the government played an important role. In contrast, in Hangzhou and Chengdu, the structures of the networks resembled those of traditional bureaucracy, and helping SOs grow was not a priority for the governments. Zhejiang province focused its efforts on service provision in institutions and met the care home bed targets set by the government. As a result, Zhejiang had the second largest number of care home beds per 1000 older people in the country. Although Hangzhou emphasised the role of socialisation in service provision, the main services were still privately funded care homes. SOs played a minor role in service provision, and both the types of institutions and types of services were limited. In urban communities, space for services was very limited. Even in wealthier communities, day centre facilities were not always available. SOs were under considerable financial constraint, while care homes managed and funded by the government were in oversupply. The occupancy rate of care homes in Hangzhou was lower than 50%. Most of the care home residents were healthy older people, and only 25% of the residents had care needs. A survey of older people’s willingness to live in the care homes showed that they had low trust in the care homes, which was associated with the fact that the homes did not have enough professional carers (Lv, 2012). Chengdu’s service networks for older people were implemented even later than Hangzhou and were very unbalanced in their development. Services were active only in pilot sites, where the local economies were relatively better. However, the government did not wish to fall behind in this round of reform. Thus, there were frequent policy changes to improve the system. Community leaders found it difficult to keep up with the fast-paced changes in government policies. While they received intensive training regarding the new policies, the capacity of SOs to meet demand was low. The more active SOs were from other provinces in the country. Even so, service capacity remained a serious issue. Even in the pilot sites, there were cases where the same group of people assumed two strands of tasks to achieve the targets of socialisation established by the government. For example, the resident committees—as the administration units at the lowest level—continued to implement government policy. Meanwhile, these units also established SOs and provided services to older people. According to the local officers, the advantage of doing this was that they had awareness of serving the communities. As employees of SOs, their services were subject to performance assessment and user satisfaction assessment. In addition, the services they provided could bring them additional income. However, this practice could only be an interim arrangement when SOs were not mature enough to operate independently. Compared with Shanghai and Hangzhou, Chengdu indicated unique characteristics in service provision for older people. Since Chengdu is an old industrial city, there are many communities where housing properties were allocated by stateowned enterprises to their employees. Residents in these communities are often people who have reached old age and have known each other since the central planning era, as colleagues working for the same state enterprises. In these communities, residents committees and party committees at the grassroots level are well

202

B. Li et al.

developed and fairly active. Many residents had lived in these communities for a long time and had formed an acquaintance society. Younger old people worked as volunteers to help older people. Some of these volunteers were appointed by the party committee or members of the party, while others simply wished to lead an active life after they retired. They cared for disabled older people as a form of home-­ based care. Meanwhile, the recipients of care trusted the volunteers, who were often their neighbours. Moreover, since these volunteers were introduced to the care recipients by the residents committees, older people were assured of receiving care, even if there were no easily accessible professional services. In contrast, Hangzhou did not have such a high level of community trust and mobilisation as in Chengdu, and neither did it have the active SOs as in Shanghai. As a result, the Hangzhou government mainly relied on private enterprises to provide services; thus, the level of service coordination and development at the community level was much lower than in the other two cities. Although there were a few active SOs in the communities, their presence was often small. The service networks in Hangzhou and Chengdu were still in their infancy. Although the SOs were not fully developed, the top-down ‘upgrading’ of the networks was rapidly progressing. For example, in the pilot sites of Chengdu, SOs had already incorporated the management of multi-layered networks into their work plans (which were common in Shanghai), even though these SOs had to be staffed by employees in the residents committees.

10.8.2  Guizhou, Xiamen, and Taicang The government of Guiyang was relatively late in its engagement with NGOs. However, this was one of the poorest provinces in China for many years, and local NGOs could not receive government support and mainly attained international funding from 2005 to 2011. These NGOs were mainly engaged in poverty reduction and human rights championship and largely worked in rural areas. In 2011, some of the NGOs decided to work with the urban government. One of the interviewees, A, stated: The reason we started to work with the government was that working with international NGOs became more difficult. The government was not happy that we use foreign money. Universities were not interested in getting associated with us. Many international NGOs contacted me; however, we dared not to take up their offers. Starting from 2011, we were seriously in debt and had to look for alternatives. Offering services to urban communities could help us to improve our financial situation.

However, a serious problem faced by Guiyang was not having qualified social workers. Past experience with international organisations led to a few people, such as A, becoming viewed as experts in working with local governments. To some extent, they became a professional organisation to help sub-district governments establish a community service platform. As they were so busy serving multiple communities at the same time, the platforms were mostly empty shells. Local officials were

10  Social Organisations and Old Age Services in Urban Communities in China…

203

unsure how to follow up and were anxious about the ability of the organisation. In each district, there were social incubators for social entrepreneurs; however, local government assumed the training responsibilities themselves. As reported by staff members of the SOs, the government was keen to show off its achievements to the outside world; thus, they invited higher level officials, the media, researchers, and international visitors to visit the sites. As a result, members of the SOs had to spend a lot of time accompanying visitors to show them around. In some cases, before the project even attained any success, the government was keen to see visible results, as they wished to showcase their achievements. Unlike the uncoordinated situation in Guiyang, Haicang in Xiamen City and Taicang in Jiangsu province had very strong governments. However, their governments’ power worked in different directions. Haicang’s government introduced a coproduction framework in which SOs were part of the Communist Party’s agenda to promote mass mobilisation and improve social control. The government was in a dominant role, and SOs were initially ‘imported’ from other provinces, such as Shanghai and Guangdong. Xiamen City is close to Taiwan and has a large number of Taiwanese migrants. Thus, Taiwanese SOs were also active in Xiamen. However, as discussed earlier, imported SOs can find it difficult to be accepted by local communities. At the time of our research, the local governments were pushing communities to accept social workers. In Haicang, older age care facilities were not well developed in urban communities; however, government-­ subsidised domestic help was active. As such, there were almost 92 types of services available for older people in Haicang. In contrast, Taicang’s government was wary of SOs. The local officials dealing with community development were highly educated and often very young. They were open to new ideas, yet simultaneously suspicious of the role of SOs. They would not mind professional care services. However, social work organisations found it particularly difficult to be accepted, as the community leaders intended to turn independent social workers into employees of the community service centres.

10.9  Discussion and Conclusion Generally speaking, China’s old aged care system has experienced multi-dimensional transformation as follows: • From single provider to multiple providers—In the early 1980s, old age care services were officially provided by the state in cities and by rural collectives in villages. However, because the level of provision was very low, family members were the primary care providers (Ngok & Huang, 2014). These days, households, the state, the market, SOs, and civil society all play a part. Within the government, there is also an attempt to promote coordination and collaboration between different government departments.

204

B. Li et al.

• From medical care to social care—In the past, old age care services were primarily offered to people in need of intensive medical care. These days, care may include non-medical support, such as household services, support for daily chores, and community-based services, organisation of social activities, and daycare services. • From administratively defined space to market-defined space—Traditionally, the service space for old age care was either defined by the state or by the market service providers. As the two types of services do not mix with each other, the service space was also defined separately. These days, as the role of different providers has become increasingly mixed, the special division is no longer as clear cut as that in the past. Policies on services for older people and local governments have proliferated in the past few years, and local governments are increasing their support in this area. Unlike existing studies, this research has used a network transition framework to examine the changing relationship between the state, the market, and NGOs. It has revealed a much more complicated set of relationships. Using goal congruency, trust and network-ness to examine the networks, we found that the networks are far from being stabilised. Despite the overall acceptance of the need to have SOs involved in old age care services, trust and coordination between stakeholders are not yet properly established. There is a low level of trust between service providers and the state, and between users and SO service providers. One of the key questions raised by many past researchers considers the willingness of governments to engage seriously with SOs. Past research has suggested that the government has many calculated barriers to make SOs’ operations more difficult, so that the former can be placed under political control. This research suggests a much more varied relationship. It is oversimplified to claim that the government has no intention of developing SOs and merely pretends to do so. The seemingly suppressive behaviour of local governments could arise from several motivations: 1. Local officials do not yet understand their new role as social venture capitalists—they either behave like private business venture capitalists or act like managers in the new public management system. They wish to hold SOs accountable, as if they are private businesses. 2. Some SOs have an overlapping scope of businesses with the existing community services offered by the government. Local officials sense the possibility for SOs to take over their own responsibilities and wish to either merge the SOs into their own organisations or push the SOs out of their communities. 3. Local officials see the promotion of SOs as being a reflection of their personal performance and wish to direct the SOs’ activities in order to highlight their own capabilities to higher authorities. In this sense, both institutions and individuals could be behind the ‘control’ of SOs, and this attempt at control could be either deliberate or unconscious. In the context of network transition, these seemingly controlling actions could be a result of

10  Social Organisations and Old Age Services in Urban Communities in China…

205

reaction to changes. Relaxation of this control may be achieved as the stakeholders negotiate their new roles. In a context of competition, as discussed in Provan et al. (2008), when there is overlapping businesses in a network environment, the efficient solution is to merge the two, rather than keeping them separate. If this is true, then some local community leaders’ argument for changing professional social workers into community service centre staff members would be a sensible solution. However, this line of argument fails to acknowledge that, without the challenges of SOs, the community service managers were not actively seeking to adopt a more professional social work approach. In our fieldwork, some community leaders had already sent their own staff members to gain professional accreditations. This means that, even without community social work SOs, the social work approach may be taken on by more and more communities in urban China. However, the legitimacy of doing this is dependent on perceptions of the nature of the network. If the purpose of the network is just to deliver services in a certain manner, it is probably better to merge the overlapping services to enhance efficiency. However, if the purpose of service delivery is to empower people and challenge the monopoly power of the state, turning SOs into government agencies may undermine this purpose. While network-ness can be an important factor in defining a network, it does not mean that the network will be sustained. A seemingly well-established network may still be fragile when the goals are not embraced by all members. Goal changes can occur at any stage of a network’s lifecycle. As discussed earlier, when a member of the network decides that he or she can acquire other network members (i.e. change a network based on contractual relations to a bureaucratic network) or the SOs cannot demonstrate their comparative advantages effectively, network members may resort to less cooperative measures, which may even lead to the collapse of an established network.

References Aldrich, D. P. (2016). Site fights: Divisive facilities and civil society in Japan and the West. Ithaca: Cornell University Press. Antrobus, P. (1987). Funding for NGOs: Issues and options. World Development, 15, 95–102. Bian, F., Logan, J. R., & Bian, Y. (1998). Intergenerational relations in urban China: Proximity, contact, and help to parents. Demography, 35(1), 115–124. Boychuk, T. (2007). Big society, small government. Macalester International, 18(1), 17. Buffel, T., & Phillipson, C. (2012). Ageing in urban environments: Developing ‘age-friendly’ cities. Critical Social Policy, 32(4), 597–617. Everingham, J. A., Petriwskyj, A., Warburton, J., Cuthill, M., & Bartlett, H. (2009). Information provision for an age-friendly community. Ageing International, 34(1–2), 79–98. Feng, Z., Liu, C., Guan, X., & Mor, V. (2012). China’s rapidly aging population creates policy challenges in shaping a viable long-term care system. Health Affairs, 31(12), 2764–2773. Fitzgerald, K.  G., & Caro, F.  G. (2014). An overview of age-friendly cities and communities around the world. Journal of Aging & Social Policy, 26(1–2), 1–18. Flaherty, J. H., Liu, M. L., Ding, L., Dong, B., Ding, Q., Li, X., et al. (2007). China: The aging giant. Journal of the American Geriatrics Society, 55(8), 1295–1300.

206

B. Li et al.

Gilroy, R. (2008). Places that support human flourishing: Lessons from later life. Planning Theory & Practice, 9(2), 145–163. Green, G. (2013). Age-friendly cities of Europe. Journal of Urban Health, 90(1), 116–128. hans Klijn, E. (1996). Analyzing and managing policy processes in complex networks a theoretical examination of the concept policy network and its problems. Administration & Society, 28(1), 90–119. He, A.  J., & Huang, G. (2015). Fighting for Migrant Labour Rights in the World’s Factory: Legitimacy, resource constraints and strategies of grassroots migrant labour NGOs in South China. Journal of Contemporary China, 24(93), 471–492. Hean, S., & Smith, S. (2013). Interprofessional collaboration when working with older people. Caring for older people in nursing, 191. Hesketh, T., Lu, L., & Xing, Z. W. (2005). The effect of China’s one-child family policy after 25 years. New England Journal of Medicine, 353(11), 1171–1176. Hewitt de Alcántara, C. (1998). Uses and abuses of the concept of governance. International Social Science Journal, 50(155), 105–113. Howell, J.  (2012). Civil society, corporatism and capitalism in China. Journal of Comparative Asian Development, 11(2), 271–297. Hsu, J. Y., & Hasmath, R. (2014). The local corporatist state and NGO relations in China. Journal of Contemporary China, 23(87), 516–534. Hu, N., & Yang, Y. (2012). The real old-age dependency ratio and the inadequacy of public pension finance in China. Journal of Population Ageing, 5(3), 193–209. Huang, X., Zhang, Z., & Li, Y. (2007). Community care diabetic foot (Tángniàobìng zú de shèqū hùlǐ). Journal of Practical Medical Techniques (Shíyòng yī jì zázhì), 14(21), 2959–2960. Huixia, Z., & Lingwei, J. (2011). Research on the governance mechanism of venture capital network. Journal on Innovation and Sustainability, 2(2). RISUS ISSN 2179-3565. Jing, Y., & Besharov, D. J. (2014). Collaboration among government, market, and society: Forging partnerships and encouraging competition. Journal of Policy Analysis and Management, 33(3), 835–842. Johansson, R., & Borell, K. (1999). Central steering and local networks: Old-age care in Sweden. Public Administration, 77(3), 585–598. Johansson, L., Sundström, G., & Hassing, L. B. (2003). State provision down, offspring’s up: The reverse substitution of old-age care in Sweden. Ageing and Society, 23(03), 269–280. Kim, S. (2015). NGOs and social protection in East Asia: Korea, Thailand and Indonesia. Asian Journal of Political Science, 23(1), 23–43. Kröger, T. (2011). Retuning the Nordic welfare municipality: Central regulation of social care under change in Finland. International Journal of Sociology and Social Policy, 31(3/4), 148–159. Le Bihan, B., & Martin, C. (2006). A comparative case study of care systems for frail elderly people: Germany, Spain, France, Italy, United Kingdom and Sweden. Social Policy and Administration, 40(1), 26–46. Li, P. (2013). Reform and future social organization system in China (Wǒguó shèhuì zǔzhī tǐzhì de gǎigé hé wèilái). Society (Shèhuì), 3(1), 10. Li, B. (2014). Social pension unification in an urbanising China: Paths and constraints. Public Administration and Development, 34(4), 281–293. Li, B., Huikuri, S., Zhang, Y., & Chen, W. (2015). Motivating intersectoral collaboration with the Hygienic City Campaign in Jingchang, China. Environment and Urbanization, 27(1), 285–302. Li, B., & Shin, H. B. (2013). Intergenerational housing support between retired old parents and their children in urban China. Urban Studies, 50(16), 3225–3242. Lieberthal, K. (1995). Governing China: From revolution through reform (p.  356). New  York: WW Norton. Liu, Z. (2006). On urban people’s commune (Chéngshì rénmín gōngshè shù lùn). Changbai Journal (Zhǎngbái xué kān), 3, 96–99. Liu, C. (2013). Chapter 6: Community governance and elite activism in urban China. In Elites and governance in China (p. 94).

10  Social Organisations and Old Age Services in Urban Communities in China…

207

Liu, X., Song, Y., Wu, K., Wang, J., Li, D., & Long, Y. (2015). Understanding urban China with open data. Cities, 47, 53–61. Lowndes, V., & Pratchett, L. (2012). Local governance under the coalition government: Austerity, localism and the ‘Big Society’. Local Government Studies, 38(1), 21–40. Lui, C. W., Everingham, J. A., Warburton, J., Cuthill, M., & Bartlett, H. (2009). What makes a community age-friendly: A review of international literature. Australasian Journal on Ageing, 28(3), 116–121. Luo, Z. (1959). People’s commune and family Issues (Rénmín gōngshè yǔ jiātíng wèntí). Academic Monthly (Xuéshù yuèkān), 2, 25–28. Lv, J. (2012). A survey of institutionalised old age care services in Zhejiang Province (Zhèjiāng shěng jīgòu yǎnglǎo fúwù xiànzhuàng de diàochá yánjiū). Master Thesis. Madhavan, R., Koka, B. R., & Prescott, J. E. (1998). Networks in transition: How industry events (re) shape interfirm relationships. Strategic Management Journal, 19(5), 439–459. Mays, G. P., Halverson, P. K., & Kaluzny, A. D. (1998). Collaboration to improve community health: trends and alternative models. Joint Commission on Quality Improvement, 24(10), 518–540. McLeod, E., Bywaters, P., Tanner, D., & Hirsch, M. (2008). For the sake of their health: Older service users’ requirements for social care to facilitate access to social networks following hospital discharge. British Journal of Social Work, 38, 73–90. Ministry of Civil Affairs. (2013). 2013 Social Service Development Statistical Communique (2013 Nián shèhuì fúwù fāzhǎn tǒngjì gōngbào), Social organizations Site (Shèhuì zǔzhī wǎngzhàn). Retrieved September 14, 2016, from HTTP://www.chinanpo.gov.cn/2201/79542/yjzlkindex. html Ministry of Civil Affairs. (2015). Old age service should be primarily home-based and community based (Yǎnglǎo fúwù yè yǐ jiātíng hé shèqū yǎnglǎo wéi zhǔ). Retrieved September 15, 2016, from http://www.ailaoweb.com/News/information/2556.html Ministry of Civil Affairs. (2016). 2015 Social Service Development Statistical Communique (2015 Nián shèhuì fúwù fāzhǎn tǒngjì gōngbào). Retrieved from http://www.mca.gov.cn/article/sj/ tjgb/201607/20160700001136.shtml National Health and Family Planning Commission. (2015). Chinese Family Development Report, 2015 (Zhtional jiiiona ffiion bbiion, 2015), China Population Publishing House (Zh2015), rr2015 chh015 shh. Ngok, K. L., & Huang, G. (2014). Policy paradigm shift and the changing role of the state: The development of social policy in China since 2003. Social Policy and Society, 13(02), 251–261. OXFAM. (2014). Chinese rural women in poverty reduction: Summary and outlook (Zhōngguó nóngcūn fùnǚ jiǎn pín gàikuàng jí zhǎnwàng). China Development Brief. Retrieved April 25, 2015, from HTTP://www.chinadevelopmentbrief.org.cn/news-16680.html Pei, X. (2004). The development and issues of long term care services for cities with aging population (Lǎonián xíng chéngshì chángqí zhàohù fúwù de fāzhǎn jí qí wèntí). Urban Mangement (Chéngshì guǎnlǐ), 36, 36–37. Pei, X. (2009). Society’s support for the aged in China: A cultural perspective. Social Sciences in China, 30(1), 149–159. Peng, X. (2013). China’s demographic challenge requires an integrated coping strategy. Journal of Policy Analysis and Management, 32(2), 399–406. Phillipson, C. (2011). Developing age-friendly communities: New approaches to growing old in urban environments. In Handbook of sociology of aging (pp. 279–293). New York: Springer. Plouffe, L. A., & Kalache, A. (2011). Making communities age friendly: State and municipal initiatives in Canada and other countries. Gaceta Sanitaria, 25, 131–137. Provan, K. G., & Kenis, P. (2008). Modes of network governance: Structure, management, and effectiveness. Journal of Public Administration Research and Theory, 18(2), 229–252. Provan, K. G., Kenis, P., & Human, S. E. (2008). Legitimacy building in organizational networks. In Big ideas in collaborative public management (pp. 121–137). Provan, K.  G., & Lemaire, R.  H. (2012). Core concepts and key ideas for understanding public sector organizational networks: Using research to inform scholarship and practice. Public Administration Review, 72(5), 638–648.

208

B. Li et al.

Rhodes, R.  A. (2007). Understanding governance: Ten years on. Organization Studies, 28(8), 1243–1264. Sandhu, S., Bebbington, A., & Netten, A. (2006). The influence of individual characteristics in the reporting of home care services quality by service users. Research Policy and Planning, 24(1), 1–12. Spires, A. J. (2011). Contingent symbiosis and civil society in an authoritarian state: Understanding the survival of China’s grassroots NGOs1. American Journal of Sociology, 117(1), 1–45. State Council. (2001). China aging development agenda during the “15th Plan” (Zhōngguó lǎolíng shìyè fāzhǎn 「shíwǔ」 jìhuà gāngyào). Retrieved April 25, 2015, from HTTP://www. people.com.cn/GB/shizheng/19/20010813/534181.html State Council (2006). Whitepaper Book of Development of Ageing Affairs in China, http://www. china.com.cn/policy/txt/2006-12/12/content_7493224.htm Steels, S. (2015). Key characteristics of age-friendly cities and communities: A review. Cities, 47, 45–52. Stepan, M., & Müller, A. (2012). Welfare governance in China? A conceptual discussion of governing social policies and the applicability of the concept to contemporary China. Journal of Cambridge Studies, 7(4), 54–71. Stern, R. E., & O’Brien, K. J. (2012). Politics at the boundary mixed signals and the Chinese State. Modern China, 38(2), 174–198. Swann, W. W. & J. L. Morgan (1992). Collaborating for Comprehensive Services for Young Children and their Families – The Local Interagency Coordinating Council. Maryland: Paul H. Brookes Publishing. Teets, J. C. (2013). Let many civil societies bloom: The rise of consultative authoritarianism in China. The China Quarterly, 213, 19–38. UK Urban Ageing Consortium. (2014). A research & evaluation framework for age-friendly cities. Retrieved from HTTP://www.micra.manchester.ac.uk/medialibrary/A%20Research%20 and%20Evaluation%20Framework%20for%20Age-friendly%20Cities_web%20version.pdf UNDP China. (2013a). China National Human Development Report 2013—Sustainable and liveable cities: Toward ecological civilization. Beijing: UNDP. UNDP China. (2013b). 2013 Human Development Report. Retrieved from HTTP://www.cn.undp. org/content/dam/china/docs/Publications/UNDP-CH-HD-Publication-NHDR_2013_CN_ final.pdf van Campen, C., & van Gameren, E. (2005). Eligibility for long-term care in The Netherlands: Development of a decision support system. Health and Social Care in the Community, 13(4), 287–296. Wang, D., & Xie, L. (2013). Chapter 5: Supply of community old age care (Dì wǔ zhāng shèqū yǎnglǎo zhàohù de gōngjǐ). In The status quo and development strategy of old age care for older people in community (Shèqū lǎonián rénkǒu yǎnglǎo zhāohū xiànzhuàng yǔ fāzhǎn duìcè) (pp. 156–157). Xiamen University Press. Weiner, B. J., Alexander, J. A., & Zuckerman, H. S. (2000). Strategies for effective management participation in community health partnerships. Health Care Management Review, 25(3), 48–66. WHO. (2014). How to make cities more age-friendly? Retrieved from HTTP://agefriendlyworld. org/en/age-friendly-in-practice/guiding-principles/ World Health Organization. (2013). What is active ageing? Retrieved from HTTP://www.who.int/ ageing/active_ageing/en/ Xiong, Y. (2014). The construction of social welfare system and development in social governance and practices in contemporary China (Xióngyuègēn. (2014). Xīn shíqí wǒguó shèhuì fúlì zhìdù de jiàngòu yǔ shèhuì zhìlǐ shíjiàn de fǎ zhǎn). Social Work and Management (Shèhuì gōngzuò yù guǎnlǐ), 14(A01), 8–10. Yan, M. C., & Gao, J. G. (2007). Social engineering of community building: Examination of policy process and characteristics of community construction in China. Community Development Journal, 42(2), 222–236.

10  Social Organisations and Old Age Services in Urban Communities in China…

209

Zhang, H. (2014). Chapter 4: Responsibilities of the government, society and households in old age care (Dì sì zhāng zhèngfǔ, shèhuì jí jiātíng zài yǎnglǎo fúwù zhōng de zérèn jièdìng). In Home based care for older people—the experience of Hangzhou (Jūjiā yǎnglǎo fúwù shūsòng jīzhì yánjiū—jīyú hángzhōu de jīngyàn) (p. 41). Zhejiang University Press. Zhang, Y., & Goza, F. W. (2006). Who will care for the elderly in China?: A review of the problems caused by China’s one-child policy and their potential solutions. Journal of Aging Studies, 20(2), 151–164. Zhong, Y. (2003). Local government and politics in China: Challenges from below. ME Sharpe. Zhong, Y. (2015). Local Government and Politics in China: Challenges from below: Challenges from below. Routledge.

Chapter 11

Community Based Social Services for the Elderly in Urban-Rural China: Investigations in Three Provinces Yi Pan

11.1  Situation and Problems The social service system for the elderly in China has not met the practical demands. Many problems are reflected especially in system design, such as shortage of facilities, funds, personnel, and policy. Based on surveys, about 5% old people want and need to receive services in various institutes. In the statistics of the Ministry of Civil Affairs in 2013, taking 5% as the standard on entrance rate, 187 million elderly population needed 9.25 million beds in institutions. China had more than 3.2 million beds, and the gap was six million beds. The investment for one bed was about 100,000 RMB yuan (which covers all the cost of manpower, water, electricity and management but not including land cost), so six million beds costed 6000 hundred million RMB yuan (now the elderly population increased to 194 million, the cost should be higher). This estimation only included the costs in institutions, not the elderly service cost in communities. The government had not funded enough for social service for old people (Ministry of Civil Affairs, 2013). Meanwhile, elderly services are lacking of the professional service staff extremely. China has 1.3 million old people in disabilities. Based on the proportion of 3:1, it would need 3.7 million people in nursing team (Editorial Article, 2010). In another professional estimated, nursing staff is needed at least ten million (Internal Paper, 2009). There are 300 thousands nursing staff in 2009, among which only 30 thousands held the professional training certificates. There are also not enough amount of institutions for providing social services for the old people. The main body of elderly service is provided by public nursing homes, accounted for 80–90%. The proportion of private participation in the social services for old people is very

Y. Pan (*) Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China e-mail: [email protected] © Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_11

211

212

Y. Pan

small. The service institutions for old people is lacking of the involvement of social and private sectors, which causes the shortage of institutions. In addition, the related social policy making and scientific designing were insufficient for the development of old-age service system. The system of social service for old people lacked good social policy of integrating funds, personal and facilities into this area. In this context, many local governments explore social services for the elderly from the perspective of community. Community is the basic unit of social and public administration in China. The unit of community is administratively settled in the neighborhood committees in city and village committees in countryside (in some rural areas community means villagers groups, in large city, for example, community is designed at street level). Different social organizations such as neighborhood committees and various social organizations, social enterprise and other professional social workers, volunteers are very active on the community-­ based platform. They are usually active powers in community living. Community is a familiar living field for old people. Under the influence of Chinese traditional culture, old people live in the community which formed their life and cognitive range, and their family members, relatives, and friends are inside the community as well. All these familiars of the living environment comfort the elderly. Generally the old people are unwilling to leave the familiar environment into a strange area. Therefore, in order to fit for the emotion and living requirement of old people, the social services for the elderly should focus on community. The old people’s daily living life, from education, catering, entertainment, to health, can be achieved comprehensively inside community. In 2007, the Ministry of Civil Affairs of China put forward the policy to speed up the development of the elderly social service, namely building up a social services system for old people which “based on the family, the community as the platform, and the institution as supplement (Dou, 2007).” Local governments in different provinces and municipalities accordingly made plans of “9073” or “9064”1 for establishing social service system for the elderly. By investigating the rural and urban situations for supporting the elderly in communities, this paper attempts to illustrate the development of social service for old people. By the end of 2009, there were 175 thousands various community service centers in China, among which comprehensive service centers were more than 10 thousands. There were 53 thousands social service stations in neighborhood committees. These community institutions play an important role in the development of social services for the elderly. These institutions with different organizations integrate different resources in different areas to provide social services for old people. For example, the hospital medical rehabilitation service combined with the aged care service; the nursing homes linked with the services of day care and home care; the catering services combined with elderly living care; other enterprises and institutions of the community supporting community services; and youth volunteers of education  Ninety percent of the elderly receive service at home, 6% of them at day care center of community, and 4% in nursing homes. 1

11  Community Based Social Services for the Elderly in Urban-Rural China…

213

department combined with community volunteers, and so on. Chinese government supports community service centers and old people service institutions through laying a material and practice foundation. Chinese government sets up a Starlight Old Age Plan. Since 2001, this plan have invested a total of 13.4 billion yuan to build 32 thousands Starlight Old People Home. The elderly social service system in community to some extent solves the problems of the shortage of social service for the elderly. However, in fact, on one hand, the social services for the elderly is insufficient and service shortfalls cannot meet the requirements; on the other hand, there are also some vacancies in service institutions and the phenomenon of misusing and wasting resources. In more than 40 thousands institutions, the total amount of beds were not enough, but meanwhile, there are still spaces in the current institutions. According to the data in 2007, the bed utilization rate in public social service agencies in city was 71.5%, and the bed utilization rate in public welfare unit of rural area was 83% (Ministry of Civil Affairs, 2008). The bed vacancy rate in private service agencies was high as well. The bed vacancy rate was 40% in the suburb of Beijing, and most of them were from private service units. At present, many social services in institutions are inefficient. Many old healthy people were living in public welfare agencies, and some of institutions had changed into the luxury places of leisure and recuperation for healthy old people. Some of these services could have been provided in communities. Such situation caused huge waste. Those old disabled people who had the need of being taken care in institutions could enter nursing homes. Most social service facilities were functioned as cultural entertainments. The comprehensive services, especially basic medical care for the elderly, were short or not forthcoming. Many service for old people were shortage in community service centers and Starlight Old Age Plan. Therefore, it was necessary to integrate social resources and organize an effective social service system for the elderly in community platforms. This study is going to discuss the community services for old people, and how those communities take their advantages on integrating various resources for social services, providing comprehensive social services. The study chooses the representations of different economic conditions and development stages, different levels of aging societies, different social constructions for elderly services, and different cultural backgrounds in China, in order to sort out the different experiences and provide effective analysis for the possibility of corresponding policies making. This research involves the big cities, the remote rural areas, and also the ethnic minority areas. Based on these considerations, this study takes accounts of the social, economic development level, public infrastructure construction and development degrees of different regions, and chooses Shanghai municipality, Gansu province and Yunnan province as the objects of investigation. Shanghai belongs to the eastern coastal developed areas, and it is the first city entering the aging society in China. Its degree of ageing is in the first place with the most rapid ageing population. By the end of 2011, old people over 65 of Shanghai was about 2.3522 million, accounting for 16.6% of the total registered population in Shanghai (Bureau of Civil Affairs in Shanghai and so on). Shanghai has characteristics of

214

Y. Pan

high aging degree, fast development, more pure old people family, and more old people in widowhood. Therefore, Shanghai is a representative city in developed regions. Shanghai, such a city with high concentrations of people and high degree of modernization, has certain forward-looking significance on the exploration of urban social services for the elderly. Gansu and Yunnan provinces are relative poor areas in the Midwest. Gansu province, with economic underdevelopment and infrastructure, is a place that typically entered ageing society but still stayed in poor. Lanzhou city is capital of Gansu province, whose land resource is very scarce. In the rural area of Lanzhou city, many old people live in empty nets when their children are migrant workers. Yunnan province is not only a remote region but also an ethnic minority area. This chapter is an analysis on three practice ways of comprehensive community services for the elderly.

11.2  Experiences in Shanghai Municipality The survey focused on Pingliang street in Yangpu district and Kangjian streets in Xuhui district of Shanghahi. The contents and measures of the community services for old people were explored from the following aspects, mental health services and cultural entertainment, medical services, life supports, and care services.

11.2.1  C  ommunity Entertainment Room and Community College for the Elderly Since 2001, Shanghai had built more than 5900 community entertainment rooms for the elderly belonging to “Starlight Old Age Plan,” basically covered all the urban neighborhood committees and rural village committees. Among them, nearly 5000 activity rooms provided qualified elderly services. There were more than 60 all kinds of the elderly colleges, more than 270 community schools for the elderly in Shanghai, and elderly classes in neighborhood committees and village committees. The elderly colleges provide abundant teaching activities for the elderly. For example, the classes of the elderly colleges of Pingliang street in Yangpu district include dancing, yoga, Er-hu, piano, painting, Shaoxing opera, traditional Chinese medicine health care, computer, photography, etc. The colleges have small libraries, where the old people can borrow books with ID card. The colleges have multi-function halls and cinemas, etc., which show the old people favorite movies every week, and hold all kinds of lectures. Four hundred thousands old people in Shanghai participated in the studies of the elderly colleges. There are about 10 thousands various community art teams organized by old people. Shanghai holds the art festival annually that lasts several months each time. Shanghai had

11  Community Based Social Services for the Elderly in Urban-Rural China…

215

hold eight Senior Games, over 60% of all the elderly participated in various forms of physical exercises. The colleges are not only the elderly recreational places, but also are places for the elderly self-fulfillment and continuously making contributions to society. The colleges offer the platforms for the elderly serving each other. Most students of the elderly colleges are the healthy younger aged, so colleges absorb the elderly volunteers to carry out various voluntary services. About one third of the students in the elderly college are volunteers.

11.2.2  Community Hospitals The old people have priorities to see doctors in Shanghai. Many hospitals have geriatrics department. The Bureau of Health and Bureau of Civil Affairs of Shanghai cooperatively promote elderly health services in communities. Community elderly service centers are equipped with medical institutions, mainly serving the elderly. Old people in Yangpu and Xuhui districts prefer to see a doctor in community health service centers, and more than 80% patients of centers are the seniors. The communities set up website linked various hospitals for medical resource sharing, and use medical resources efficiently for social services. Community service centers have physical examination department, and establish community elderly health records. More than 90% of the old people have their health records in communities. Kangjian community hospital in Xuhui district is co-financed and co-built by the Bureau Civil Affairs, Bureau of Health, and Kangjian sub-district office. The total investment is more than 300 thousands Yuan. Both Bureau of Civil Affairs and Bureau of Health allocate certain amount money for old people’s physical examination in communities. The physical examination center opens once a week, and most of the physical examination projects are free. Shanghai carries out the system of family medical doctor for old people. After doctors and the elderly sign agreements, the local government budgets 10 yuan from accounts of medical insurance each month to the doctor and his team (a doctor and one or two nurses). The community hospitals in Shanghai explore the family sickbeds and provide home care services for the elderly disabilities in communities, solving the problem of the inconvenience of the medical treatment for the elderly. Many community hospitals turn into another nursing home in fact. For example, Kanjian hospital provides bedside care and hospice care services. The community service center is equipped with mental health service rooms for the elderly. The old people can come here to talk and to release themselves from accumulated problems. The community health service centers and community service agencies for the elderly have cooperative activities. The community health service center arranges the doctor to treat old patients, make up a prescription, and send medicines to old people. This way is so convenient for the elderly who lived in institutions.

216

Y. Pan

The communities promote the ideas of health interventions, namely non-medical treatment to intervene health. The social organizations carry out health intervention activities in the communities. The Old Partnership Project is a content of health interventions. The trained young-old are organized to deliver services, mainly the health education services, to who over 80 years old. At the year of 2013, Shanghai had trained 20 thousands elderly volunteers to provide health education service for the 100 thousands the oldest elderly who live alone in communities.

11.2.3  Community Service Center and Personal Care Service These services adopt the suggestions of the elderly in the communities and are designed according to their basic requirements. The local standards of the elderly services in Shanghai are classified into ten categories. The communities establish care (support) service stations for the old people, day care centers (nursing homes), the service stations for the disabled elderly, social service organizations for home-­ based care, etc. These agencies constitute the basic conveyor of home-based services. The total of 33 thousands caregiver and care assistants worked in the elderly home-based care in Shanghai communities. There were 326 day care centers for the elderly in Shanghai and each street had a day care center at least (The internal document of Bureau of Civial Affiars of Shanghai, 2013). Shanghai had begun setting up catering service points for the elderly since 2008. There were 475 catering service points by 2013 and averagely each central community of the city had 3–4 catering service point. The catering service points provide meals for the students of the community elderly college. The old people register for meal in the morning and paid 7.5 yuan. Then they can have a lunch, including one meat dish and one vegetable dish. If old people can walk, they should be picked up to the community centers to have meals and participate in activities. Several districts in Shanghai ask the social service centers for the elderly in communities to do this task. This service is meant for increasing the opportunities for the old people communicating with others and society. The meals are sent to homes only when old people lose capability of action. The local government applies the quasi-market mechanism as management principle: buying services from the service  entities. Pingliang street issues service vouchers for the  living difficult old people. The service vouchers are distributed after evaluation. The standards of assessment consist of family economic condition and the requirements of the elderly services. The evaluation of criteria for family economic status is people over 60  years old with the minimum living guarantee allowance or old people from low income families. The assessment for service needs can be divided into three levels: light, medium, and heavy. Each level is corresponded to a certain amount of service voucher. Assessment methods are used a set of evaluation criteria designed by Shanghai. The purpose of assessment is the fairness in distributing resources for the group with immediate demands. The local government supports full payment for the old people with the economic difficulties,

11  Community Based Social Services for the Elderly in Urban-Rural China…

217

while the old people without economic difficulties buy services by themselves. There is also people with a kind of intermediate state. The very old people whose self-care ability is weakened, and the requirements for care service are emergent. Shanghai government issued a supplement policy for the people aged over 80 years in 2008. If the pension of the elderly above 80 was below the average level in Shanghai, they could have half services subsidies provided by the government. The other half cost was still paid by the elderly themselves.

11.2.4  Service Institutions for the Elderly in Communities The social service for the elderly in Shanghai is designed as “9073” pattern, which means 3% of the elderly are in the institutions (90% are in home care, and 7% are in day care center in community). The public service institution belongs to the state with public nature.2 It firstly ensures the old people with low-income, incapacitated and mental disabled, and then expands services to all the elderly who belong to community, to empower the community as the support platform for the old people. Shanghai had issued nearly 40 support policies for social service institutions for the elderly since 2004. Based on these policies, Xuhui district implemented 17 support policies of home care and institution care for the aged people. Social Welfare Home of Yangpu district carried out a project of “Carers’ home.” Local government entrusts the institution to deliver  this service to the belonged community, which make the fullest use of the resources of elderly services in this institution, and perfectly combined the institutional old-age care with the community old-age care. Aiming at the problems of the shortage of nursing staff and professional knowledge, the project of “Carers’ home” provides professional nursing training, psychological counseling, and social support for the home carers in the community. “Carers’ home” also launched support programs such as “respite care.” Nursing staff of Social Welfare Homes deliver services to the homes of old people, and home carers can make a break, in order to release their tensions and relax their minds. These are fee-based services. When professional nursing staff provides on-site service supports to caregivers in communities with professional technology, the institutes increase incomes. Shanghai pays attention to roles and functional divisions of public welfare institutions and the private nursing institutions, as well as how to integrate the two together to maximize social benefits. Private welfare institutions work as a supplement to public institutions to release the pressure of the latter. They offer more options to meet the different demands of old people in different economic situations. Xuhui district government funds 200 yuan subsidies for each resident per month in the private institutions. At the same time, after 5 years running of private  The local governments at different levels have established public service institutions and regulation officially issued to guarantee the needs of the old people with low-income, incapacitated and mental disabled in the past. 2

218

Y. Pan

institutions, Xuhui district government, based on the evaluation of overall equipment, funds them about 20% of maintenance repair costs. The communities have not set up the accident liability insurance, but Shanghai government has made a unified plan for it. The budget is from municipal administration, district and institutions three levels, and each one is responsible to finance one third. Such policies raise the enthusiasm of the social organizations building welfare institutions. Public and private beds and institutions in Xuhui district each accounts for 50%. The nursing homes in Shanghai suburb are complementary with the urban nursing homes. Xuhui district sets up a series of adjustment policies. The old-age homes of urban and suburban have the links as counterparts for mutual help. The local government subsidizes the nursing homes in suburbs when they offer beds for urban old people. At the same time, the local government issues subsidies to the elderly of urban communities who choose to stay in the suburb nursing homes. The two-way subsidy policy encourages the elderly to move to rural nursing homes, effectively improving the efficiency of resource usage. Shanghai city pays attention to the benefits of nursing assistants, and government offers the nursing posts subsidies. The certificated nurses, according to initial, medium, and high levels, receive allowances 100, 200, 300 and 400 yuan. Technical personnel also have subsidy in the level of 200, 300, and 400 yuan.

11.2.5  Roles of Professional Social Workers and Volunteers Shanghai has a large number of professional social work organizations. The services of social work permeate into all areas of aging services in Shanghai. The professional social workers carry out management, organization, and planning in Shanghai senior universities, old-age institutions, the elderly service centers, health service centers, the elderly legal counseling centers, and psychological comfort service points in communities. The social workers in Yangpu district become the main force of the elderly service in communities. The professional social workers successfully organize the work of the old people university in Pingliang street and make an excellent management service model. Yangpu district established professional social organizations in 2010 and enabled to bid for the Shanghai public service bidding projects. Pingliang street bid the project successfully, and it undertook the management work for more than 60 geriatric activity rooms in four streets. Professional social workers of Pingliang street designed the contents, activities, and themes of more than 60 activity rooms for the elderly. The teaching work of the activity room for the elderly in Pingliang street was successful and played a good role. It created a set of rich service items and efficient management mode, which is expanded to other three streets. Shanghai vigorously supports social work organizations. Shanghai municipality provides free offices to newly established social work organizations, with an initial subsidy fee of 20 thousands yuan. The local government also provides training and compensation subsidies for social workers and psychological counselors based on

11  Community Based Social Services for the Elderly in Urban-Rural China…

219

their qualifications, work, education, the number of paper publications, etc. In 2013, the standard of social worker compensation subsidy was 400, 600, or 800 yuan per month. In addition to support social workers, Shanghai municipality also actively promotes volunteer’s service, absorbing students, professional and technical personnel, laid-off and unemployed people, retirees, and younger old people into volunteer teams to provide services for the aged. From 2004, Shanghai began to carry out a program of “care activities for the elderly people living alone.” Community youngold volunteer provided paired services for old-old people who lived alone in the communities. The community volunteers, through regular door-­to-­door visits, telephone interviews and water, electricity, and gas safety checks, care the elderly people living alone. “Old partner program” is for training the young-­ old in the community to offer their services for older people over the age of 80. In the “old partner program,” one young-old volunteer contacts with five old-old people. The old “partners” enter the homes of the aged who live alone or call the old people who cannot leave the rooms. The young-old volunteers should know the difficulties of the served old-old people and solve their problems. Shanghai municipality had trained 20 thousands young-old volunteers to provide health education service for 100 thousands old-old people in communities. Shanghai municipality fully uses the resources of a series of elderly volunteer organizations, such as the Association of Old Scientific and Technological Workers, the Association of Veteran Journalists, the Association of Senior Teachers, etc. These activities mobilize the enthusiasm of the young-old to participate in voluntary services, promote the exchange and integration of community members, and at the same time provide a platform for the elderly devoting their remaining energy and make contributions to the society.

11.2.6  M  anagement and Operation Mechanism of Community Comprehensive Service for the Elderly In 2010, the Bureau of Shanghai Civil Affairs launched “Public Welfare Project bidding.” The district government puts forward the demands, covered areas and investment amount of the services, and the Bureau of Civil Affairs of Shanghai is responsible for the operation of this project. After the online publication, social organizations bid, the Bureau Civil Affairs of Shanghai made the organization evaluation. The Bureau of Civil Affairs granted project funds and supervised to the winning bid organizations. The allocation of funds was in proportion of 4:4:2. At the start of the project, the initial capital was given 40%; by the halfway of the project, it should submit the mid-term evaluation report of the project. According to the progress of the project, the medium term of 40% allocation was funded. Thereafter, the third party, the Social Work Association, was commissioned to do the evaluation work. The winning bid organizations should submit monthly plan, summary, activity photos, other activities archive, and so on.

220

Y. Pan

The final 20% fund was allocated on the basis of the medium-term assessment report and development of the project. The management mode of the home-based social service for the elderly in communities of Shanghai has three levels: the guidance centers of home-based social service for the elderly of Shanghai; the guidance centers in districts (counties) levels (together 17); and at street subdistrict office level. The service guidance center exercises the power that entrusted by the local government to manage the service entities in grass-roots, and it is responsible for the pre-settlement of the annual subsidy funds, the examination of application of the elderly services, physical evaluation, training of service teams, monitoring of service quality, tracking and inspection, etc. The funds of management and operation are purchased by the government.

11.3  The Experiences in Gansu Province Based on the situations, Gansu province integrates various resources to explore new ways to provide social services in old people’s home for the aged. In urban communities, the government establishes virtual nursing homes. The platforms attract enterprises to join, and jointly meet services and demands. In rural communities, the government uses idle resources for example abandoned schools to establish mutual help homes for the elderly. The local government advocates neighborhood mutual help and the elderly self-help to solve the problems of lacking of care and spiritual life void in empty nests.

11.3.1  The Virtual Nursing Home in Urban Areas There are 1.3 million permanent residents and 167 thousands elderly residents in Chengguan district of Lanzhou city, Gansu province and old people accounts for 17% of the resident population with 3% increasing rate per year. With limited lands, insufficient infrastructure, and inadequate service manpower resources in urban areas, the local government isn’t in a position to set up enough physical institutions, for example nursing homes to meet the needs of the elderly. At the same time, some social resources are idle in Chengguan district. In December 2009, the government of Chengguan district set up an information platform for the elderly care services, which called the social enterprises to join. It organized various forces to provide services to the elderly population over 60 years old (women over 50) in Chengguan district in all aspects of their needs. The demands and services got connected. The main body of virtual nursing home is a service platform, a hotline, and a group of enterprises. In 2012, as many as 98 enterprises joined, and they provided ten categories of services including living care, medical care, health care, rehabilitation, psychological comfort, legal advice, homemaking and live care, entertainment and learning,

11  Community Based Social Services for the Elderly in Urban-Rural China…

221

palliative care, food services, and more than 230 kinds of services. More than 80 thousands old people joined, accounting for half of the total old people in the urban area. The number of long-term service receivers exceeded 20 thousands, accounting for 12% of the total number of the elderly in the urban area. This integration pattern had been extended both in the content and areas. In Lanzhou, Chiuguan, Jinchang, Baiyin, Tianshui, and other cities, the care services for the elderly in this way reached 80%.

11.3.2  T  he Government Setting Up a Platform, and the Social Forces Join The construction mode of virtual nursing home in Chengguan district is the government leading and social powers participating. The virtual nursing home is set up and funded by the local government, fully mobilizes and uses the social service resources. All business enterprises and social groups who have the service capabilities are integrated into this virtual platform, concentrating on providing services for the elderly. Through this platform, the elderly know the accessible services and where can get them. In addition, the enterprises also know the needs of the elderly. It avoids the information asymmetries between the business service and the needs of the elderly and meets the needs of the elderly faster and more efficiently. Meanwhile, the waste of idle resources is avoided, and the local government’s investment in facilities and personnel is reduced. The elderly need only one telephone and then receive the service at home. The government also monitors the personnel service work and ensures the quality of the service through the feedback of the old people and the information platform. The government gives preferential incentives to virtual nursing homes. Old people who join virtual nursing homes can get 20% discount below market price or other subsidized prices when receiving services. For example, the cost of a meal in restaurant is around 15 yuan, where the elderly only pay 6 yuan. The other 9 yuan is subsidized by the local government. According to the economic conditions and the abilities of old people, virtual nursing homes divide them into three categories as A, B, and C to offer care services to them. Class A means the old people in “three none3” and other old people who need special care and they freely receive services. Based on the conditions of their health, the government issues different levels of subsidies to them, and service enterprises regularly provide personnel service to the homes of old people. Class B is the priority care group, including the elderly over 90 years old and the old people who get higher honors. They receive the subsidy of 50 yuan per month from the government. Class C are “ordinary” old people. They buy services through the government platform, which is 20% discount compared with the average price of the market. The local government also has  No family members’ support, no work capability, and no incomes.

3

222

Y. Pan

preferential policies for these enterprises that joins this platform. The platform provides fixed and stable service objects for the joined enterprises. Lanzhou city is working for the tax relief policy for the joined enterprises.

11.3.3  Mutual Help Home for the Elderly in Rural Areas There were 41,407 old people over 60 years old in Baiyin district of Gansu province, among whom 11,933 were in rural areas in 2013. The empty nests in rural areas accounted for 57% of the total elderly population in rural areas, and the degree was very high. According to a survey of Ageing Commission of Baiyin district in 2012, 4% of old people in empty nest would like to live in nursing homes to receive care services, and 96% of the elderly wanted to live at home. In 2011, Baiyin district explored the work of building the mutual help happiness homes for the elderly in rural areas. It aims to provide a place of getting together, exchanging information and amusement in daytime for the rural old people. As their wishes, the old people can either spend night in the happiness home or go back to their own home at night. The mutual help happiness homes mainly provide services for the empty nest elderly in villages. They are live alone old people and their children are migrant workers left homes for a long time and have no one to take care of them at homes. Building rural mutual help homes for the elderly is based on the principles of “village committee hosting, mutual assistance, government supporting and mass participation.” First, the local government takes leadership to make policies, design overall plans, and offer financial supports (allocate part funds from the collective economy and provide basic equipment). Second, various departments and all kinds of industry units provide support and help. The construction of mutual help happiness homes for the elderly in rural areas is linked with the “double actions” of the Party Committee and Provincial Government of Gansu province. That is to say, the different departments of provincial authorities join the actions of mutual help happiness homes for the elderly in rural areas, directly contact villages and households, and provide human resources and material resources. Third, the services are provided through villager voluntary services, mutual assistances among the young-old, mutual assistances between the young-old and the old-old, and self-help of old people who lived in the mutual help happiness homes. In the construction of mutual help happiness homes for the elderly in rural areas, the local government puts forward plans, issues policies and provides financial support. Party Committee and Provincial Government of Gansu province, Bureau of Civil Affairs in Gansu province, and government in Baiyin District all issued documents and concreted on implementing plans. The Bureau of Civil Affairs and the Bureau of Finance in Gansu province invested 15 million yuan yearly in 3-year continuous construction of mutual help homes for the aged and the five-guarantees4  Gurantee foods, clothing, housing, healthcare, and funeral for the elderly with no family members, no working capability and no income support. 4

11  Community Based Social Services for the Elderly in Urban-Rural China…

223

homes in Gansu province, improving the facilities for the elderly in the countryside and laying the foundation for the development of the rural mutual help happiness homes for the elderly. The Bureau of Civil Affairs in Gansu province spent ten million yuan per year from the welfare lottery fund to invest and fulfill the construction of the mutual help happiness homes in 5000 villages of whole province. The Bureau of Finance of Baiyin District also provided financial support. The local government of Baiyin district spent 1.52 million yuan in 2 years for establishing and maintaining the infrastructure in the mutual help home for the elderly. The Government of Baiyin district also allocated part funds of the collective economy to the Aging Association to maintain the functioning of the mutual help homes. At the beginning of 2012, the various government departments of Gansu province linked poor villages in 58 poor counties with units, and the cadres worked together to help special hard households as the main contents of the “joint village joint household for the people becoming rich” action, which built the linkage of four levels in the province, city (prefecture), county (district), and township. Dual action provided financial and intellectual supports for the establishment of the mutual help homes in a twinning manner. The local government allocated part funds of the collective economy, which managed by Aged Associations in village, to maintain the operation of the mutual help homes. The principles of building rural mutual help happiness home are that government supporting, neighborhood mutual assistance, family helping each other, and social donation. The model of rural mutual help happiness homes combines the advantages of three modes, family care, collective support, and social services. It integrates the different resources of government, society, and family. Social forces through financial support and volunteer services participate in the construction of rural mutual help happiness homes for the elderly. Entrepreneurs and villager volunteers are involved in building of mutual help homes. In Silong Village and Yongxing Village in Baiyin District, the rich people of the villages make contribution to the mutual help happiness homes. The mutual help homes for the elderly are built conveniently in the same location of the village center, the health station, and offices of the village. Kindergarten of village is built next to it, and women in the villages come to have square dance in the central playground at evening. It feels a big family. In 2011, an entrepreneur of Silong Village contributed 100,000 yuan as the operating expenses for mutual help homes. All mutual help homes in Baiyin District were rebuilt by the village center primary schools. In 2001, the State Council adjusted the distribution of compulsory education schools in rural areas and students were concentrated study in central villages5. The idle village primary schools were reused and saved the cost of construction. These schools’ were located in the middle of villages which unique central geographical advantages in villages bring convenience

 The numbers of students in rural areas are getting less, so schools building in every village are changed to be built in a central village and students from surrounding villages go there to study. 5

224

Y. Pan

for the operation of the mutual help homes. The idle houses in villages reformed and reused again as well.

11.3.4  Self-Management The Aged Association of village is responsible for the construction and operation of the mutual help happiness homes for the elderly in rural areas. All 45 administrative villages in Baiyin District have set up Aged Associations of village. The Council of Aged Association is democratically elected and serves as its daily governing body. The council is generally composed of 5–7 members, who are old people with highly respected, high prestige and the strong drawing power, and enthusiastic about public welfare activities. The president of Aged Association is generally elected from village cadres (village leader can give better support for social services of the elderly if taking this position), and vice chairmen are elected among the elderly. In order to enable more old people to play an active role, the local government actively supports the Aged Association and encourages old villagers by voluntarily organizing or joining it. The Aged Association is self-management and provides self-services. They are unified scheduling and allocating endowment resources, ensuring the effective utilization of resources, improving the social participation of the elderly, and enriching the spiritual and cultural life of the villagers. The mutual help home of the elderly combines mutual help and self-help. The mutual help homes of the elderly in rural areas have these actions, such as mutual assistance between urban and rural areas (dual actions), cadres and the masses united assistance (officials provide one to one help to old people in empty nests), neighborhood mutual aid, the elderly mutual help, and so on. These mutual helps complement each other, together form social force for the elderly services, and make up for the lack of family responsibility. In addition to mutual help, the elderly self-help is also a feature of this model. In the mutual help home of Silong Village, a volunteer who cooks for the elderly, is an empty nest old woman. She used to be a woman cadre and now she feel alone at home. So she goes to the mutual help home to do catering and cleaning services and becomes the main staff member. There is a piece of land in the courtyard of mutual help home, and the old people grow vegetables according to the season. They get material self-sufficiency and meanwhile make physical exercise. The mutual help home of the elderly has combined the inside service and services from outside. The mutual help home of the elderly through the outside service solves the daily care needs of rural old people in empty nest. On the one hand, the homes attract scattered old people of empty nests who live outside of the courtyard to join the actions of the homes. These old people’s families still bear the responsibility to take care of the elderly. When old people live inside the homes, their children need to pay certain fee to the mutual help homes yearly. Although the children of the elderly in empty nests cannot take care of their parents by themselves, they cannot ignore their responsibilities and obligations. When the elderly are ill

11  Community Based Social Services for the Elderly in Urban-Rural China…

225

and in need of special care from family, the homes notify their family members to take care of the elderly at home. On the other hand, village cadres and volunteers carry out “twinning services” and “appointed fixed time” visiting system, to provide supports when the elderly need. The mutual help home offers services to all old people of the village. For example, there are only 11 old residents in Silong mutual help home, but at least 30 old people come here to spend time every day, which is equivalent to 1/7 of total old people in the village. These old people receive services indirectly. The homes provide a place for the elderly to meet and entertain, enrich their spiritual life.

11.4  Experiences of Yuxi in Yunnan Province Yuxi city, in Yunnan Province, is located in the ethnic minority areas in the south part of China. The characteristics of community comprehensive social services for the elderly are the driving roles of the senior universities, and the universal establishment of senior centers and the organization and management of the Aged Associations.

11.4.1  The Development of University for the Elderly Yuxi University for the aged in Yunnan Province was established in March 1991. After the expansion in 2009, there was a six-storey teaching building with 8860 m2. By 2012, the university had 10 departments and 35 specialties. There were 80 classes and more than 4500 aged students. During 21 years, more than 46 thousands students are enrolled. Thousand old people come to study in the university each day. The university is located in downtown and has great influence in Yuxi City. Yuxi University for the aged explores the development in three aspects. The first is to run the qualified university education for the aged, and to absorb more the elderly who live in city center to study; second, training the backbone of the elderly so that they can spread what they have learned in the community; and third, the university brings the teaching into communities for the elderly, and organize recreational and health activities for the elderly in urban and rural areas. The design of curriculum has local characteristics to meet the wills of the elderly. The idea of the university for the elderly is healthy, happy, and joyous. The university offers a wide range of courses and subjects for the elderly, so that they can learn according to their interests. When designing a course, the university asks the opinions of the elderly through a variety of channels. Health course is very popular in the elderly. The classes of Chinese medicine and Western medicine care attract up to 200–300 aged people to participate. The curriculum of the university is close to the life of the elderly and follows the local culture tradition. Yuxi is the hometown of lanterns, and lantern dance is the main characteristic of the place. The university

226

Y. Pan

specially sets up the Department of Lantern to teach lantern singing and dancing, and continues the local cultural tradition, which is very popular among the elderly (The Ageing Committee of Yuxi Cit University of the Elderly in Yuxi, 2011). The university pays attentions to the role of the backbone of the elderly. It cultivates the strength and exerting of the elderly to help themselves. Teachers at Yuxi University for the aged have hired retirees. The teacher who teaches lantern dance and local operas are retirees, and the principal of the university is also a retired teacher. The aged students actively return to the communities to spread knowledge to the masses and after learning. The teaching is put into practice, the backbones of the aged people organize the other elderly to dance in the community square, create an active and healthy environment for the aged in the whole city.6 Yuxi University for the aged is not only limited to thousands of aged students in the urban area, but also being as a center to expand and promote rural communities. In the festival season, Singing and Dancing Performance team of the university go to the rural communities, as the achievements of the university, to “Send Plays to the Countryside,” and let rural old people enjoy amusement. The university establishes a network of five levels of geriatric education. In order  to involve more older people, including those in rural areas, to learn, the university sets up online learning. The five levels of senior education network of Yuxi university are that geriatric schools or classrooms established in city, county, township, village, and villager groups, and the elderly can participate in the network teaching classes at home. The university distributes teaching CD-ROM to the rural elderly and centralizes study in the village geriatric classroom. Thereafter teachers of the university, as coaches, go to the countryside and carry out teaching activities. The “Happy elderly Class” developed by the University is meant to deliver the education to the elderly who cannot attend classrooms studies.

11.4.2  Building Aged Centers Yuxi City has built 3400 activity centers for the elderly in communities to facilitate education and cultural recreation in universities’ branches for the elderly. When a newly community is planned to construct, the local government set a piece of land to build a community nursing home and a activity center for the elderly, so as to avoid the embarrassment of no land to build these institutions when the community is mature. Yuxi Municipal Government has invested more than 1.5 million yuan to establish a service platform named love and respect the elderly. It provides services for the elderly in urban and rural communities. Even in rural centers for the elderly, the network of computers stores all kinds of information of the village elderly and teaching files of TV universities.

 Square dancing is good for the mental and physical health of the elderly, which builds up their bodies and meanwhile reduces their loneliness. It fits the concept of active and healthy aging. 6

11  Community Based Social Services for the Elderly in Urban-Rural China…

227

Family supporting aged is still the main way of providing care services in Yuxi. The survey shows that the most urban and rural residents in Yuxi wish to receive cares from their families. The main reason is that Yuxi is not a very big city, and the economy and society are harmonious development. Besides, the traditional culture and moral standards are inherited and maintained in society and family. In addition, Yuxi has the concept of active and healthy old-age care, the elderly generally go to the fitness and entertainment in community squares and the elderly activity centers. In a slow pace of life, the majority of the elderly maintain the physical and mental health. Although the elderly are not rely heavily on the government, the local government is aware that the requirements of the elderly will increase and change. In that sense, the local government began to improve service facilities of communities and actively prepares to cope with the aging society. Each ageing center designs a special day-­care center for the elderly. Although no one checked in at the beginning, the infrastructure was already in place. There are 83 public nursing homes for ageing with 2950 beds in Yuxi city. There are four private ownership nursing homes, with a total of 250 beds. The government encourages the establishment of private owned institutions. Per bed of private ownership institutions get the subsidy of 2000 yuan from the local government.

11.4.3  Universally Sets Up the Aged Association The comprehensive social service activities for the elderly in communities in Yuxi City, Yunnan province, are mainly organized and delivered by the Aged Association. The role of the Aged Associations is more pronounced in the countryside. Six hundred and seventy two village (residential) committees in Yuxi city set up the Aged Associations, which are the self-governing organizations of old people. There are 4489 village (residential) committees set up the branches of the Aged Associations. They are accounted for 69.3% of total village (residential) groups. Two hundred and fifty two thousands old people joined the Aged Association, accounting for 78.9% of the total number of old people (Zhou, 2011). The committee members of Aged Associations are generally composed of 5–7 old people, and mostly are volunteers. The elderly who joins in the aged Association pays a nominal fee of one yuan to strengthen the elderly’s identity with the Association. The community collective economics support the actions of the Aged Association. According to various situations, the elderly are given different benefits monthly. These subsidies are counted and assured by the Aged Association. The Aged Associations organize the elderly to participate in various activities in the Aged Centers of community. The Aged Associations send birthday cakes to old people in their birthdays. The Aged Association receives supports from village committees, including venues and funding. The Aged centers usually locate in the most important centers of the communities. Many aged Associations set up economic entities and enable themselves to maintain basic funding for the activities.

228

Y. Pan

11.5  D  iscussion on the Experiences of Integration of Community Old-Age Service Resources in the Three Places Three places integrate different resources for the comprehensive social services for the elderly in community. Various social forces participate in social service and form the supporting pattern for the old people services to meet the needs of all aspects of the elderly. Different people, organizations, departments, and agencies, with combination of material and human resources and technical methods, achieve the maximum use of social resources for the elderly services in communities. In these practices, the three places have successfully integrated different types of management structures and areas, such as government, business enterprises, and social organizations in urban and rural areas to meet different levels of social services in local communities. Social forces include associations, volunteers, self-­ governing organizations, private enterprises, and so on. These social forces are quite different in three places. Shanghai’s institutions and social organizations cooperate with each other. In Gansu province local governments build platforms, and non-­ governmental organizations participate in producing services. Three places integrate different resources of various government departments. The elderly has needs for medical, living, and mental services, which have close ties. They interact with each other, thus the services could not be provided by single department. These services have been integrated in communities. For example, the Bureau of Health and Bureau of Civil Affairs in Shanghai work together to establish health service centers in the community. Meanwhile, they combine social relief and legal aid for the elderly to integrate resources effectively. Three places integrate resources between urban and rural areas. They transcend the boundaries of urban and rural areas and achieve the integration of urban and rural resources. For example, when numbers of nursing homes were short in urban communities, Shanghai municipality linked urban communities with private owned nursing homes in the suburbs and gave preferential policies. The urban elderly who wanted to go to nursing homes in the suburbs received subsides. The nursing homes in rural areas also received government’s support when they accepted the elderly of city. The construction of rural mutual help homes for the elderly in Baiyin district of Gansu province has been supported by the city and village joint operation, which has resources from material, capital to manpower. Yuxi city in Yunnan Province used the five-level network of the University of the elderly to deliver entertainment and education services to the urban and rural communities. Three places integrate the social and market resources into the community services. The virtual nursing home in Gansu province is a typical example, setting up a platform to introduce enterprises into the field of the elderly services. At the same time, the government’s platform and social enterprises’ platform cause a complementary and competitive situation. Entrepreneurs of rural Gansu take the way to raise money. Shanghai then applies the rule of the quasi-market purchases services

11  Community Based Social Services for the Elderly in Urban-Rural China…

229

from social organizations. The market mechanism of Yunnan province is not obvious, but the collective economy of the community has given great support to the community activity center for the elderly. The elderly volunteers participating in social services is a way of integration of human resources in three places. Shanghai vigorously developes voluntary services and fully explores available human resources, including the laid-off workers, unemployed, and retirees. Shanghai through the Old Partnership Program and other ways to establish a strong old people resources support system of community. The mutual help and self-help of the elderly in Gansu province and the volunteers and Age Associations in Yunnan Province, etc., have become the new forces of community services. They make an integration of material and financial resources. Through unified planning and management and expansion of radiation radius of services, Shanghai has realized the efficient utilization of service facilities. The hospitals, elderly activity centers, and nursing homes in communities have been fully utilized. For example, the activity center serves as a day care center; the nursing homes also provide meals for the elderly in the community; and the hospitals provide health care and hospice care for the elderly in the community. Shanghai fully uses the resident unit’s resources. The outdoor activity spaces are limited in the urban Shanghai area. In order for the elderly to do as much physical activity as possible, Shanghai’s municipality makes cooperation with nearby universities and agencies, for instance in the community, and the elderly can go to the sites of these units to exercise. To avoid the problem of responsibility, the local government bought health insurance for the elderly. This makes full use of the resources of resident units, to meet the needs of fitness and entertainment of the elderly. The mutual help homes for the elderly in the countryside of Gansu province integrate various resources. During the operation of the mutual help homes, material resources such as physical funds, playgrounds, and facilities (including schools, old village offices, infirmary, etc.) are used in social services in rural communities. Meanwhile, some small equipment such as stoves, beds, TV sets, and other appliances have been fully utilized. In addition, the measures of management, organization, operation, and complement in integration of service resources of the community comprehensive social care services for the elderly are different in three places. Shanghai’s government gives full play to the role of professional social workers’ organization when purchasing services. Social workers organize the various resources in the transmission and completion of social services for the aged. Gansu province plays fully the leading role of various government departments, jointing villages and households to promote rural mutual help home for the elderly. Since not every old person can come to the university for the aged located in central city, Yunnan province sets up the classrooms of the university for the elderly in the service centers of communities. The way of five-level television teaching network integrates technology and methods for the elderly, and teachers regularly tutor the elderly on-site, so that more old people can receive the education of the university. Gansu province also makes full use of modern technology to build a virtual nursing home platform. The city

230

Y. Pan

holds virtual nursing homes with different government departments and social resources, and integrates all kinds of resources on a single network platform to provide comprehensive services for the elderly. In the integration of organization mechanism, in the rural areas of Gansu and Yuxi in Yunnan, there appear self-governing organizations of the elderly, and the Aged Association plays a leading role for the old-age service in the community. Especially in Yunnan province, the Aged Association as a voluntary organization for the elderly is popularizing, forming, and implementing the network of organizations in the comprehensive services for the elderly in the community. Shanghai absorbs the public sector and an enterprise group, non-profit organizations, and families together to develop the elderly services in community. From the practices of three places, we can see that resource integration is embodied for the relief of the pressure and the limitation of the supply of services for the elderly at different levels of economic and social development. It is advantageous to break through the bottleneck of the restriction of service resources and surmount the obstacles of the current service shortage. Therefore, the local provision of services for the elderly should be tailored to local conditions, rather than being unified. Although the economic levels of the three regions are not the same, they all pay attention to meet the needs of the elderly through the local old-­age service. Three regions have formulated the old-age social service policy which are suitable for the local characteristics and levels. Experiences have proved that the social services for the elderly can be carried out in areas with relatively backward economic development level. At the same time, it also shows that it is not sure a place with a heavy task for the aged service and many difficulties, the old-age service should be lagging behind. There is no one-size-fits-all neatly planned social service policy for the elderly in the three places. The three places have different experiences in resource usages, in the ways of integration, and in management modes. They effectively transport comprehensive social services in the community, which is worthy of promotion and reference to enlighten the different experiences of different regions in China. In addition, the local governments play a decisive role in policy design. Faced with the same resources, the same conditions, the local governments pay attention to the livelihood of the people, to the elderly social service, careful planning and design, produced different results. Whatever the local governments build platforms directly or urge social worker organizations to provide social services for the elderly, it is only under the initiative of the government, the supports of funds, personnel, and policy would be effective. Macro-strategic decision-making is the key to promote the development of social services for the aged. The policies determine the old-age service development, which are responsible for the way and content of providing services for the elderly. Finally, the experiences of the three regions have positive significance to bring forward macro-policy guidance at the national levels and promote pension service. The cases of the three regions show that the society and communities have rich resources for social services, and social strength is the potential qualifications of services. The key lies in how the government integrates and mobilizes. The social

11  Community Based Social Services for the Elderly in Urban-Rural China…

231

resources need to be organically combined with the departments of public administrations and actively mobilized in order to complement with each other. Organizing and integrating different kinds of sectors, on the basis of a community, including social organizations, social enterprises, the profit-making sectors and volunteers, is prominent to accomplish the task of providing services for the elderly.

References Dou, Y. (2007, October 23). Bureau of Civil Affairs in Shanghai, Shanghai Committee on Ageing, Bureau of Statistics of Shanghai (2011), Internal Statistics Report on Ageing of Shanghai, Social welfare would transfer from a residual type to moderate universalism. Public Welfare Times. Editorial Article. (2010). China’s old people support strategy should have a major breakthrough during the 12th Five-Year Plan period. Journal of Nursing Home, first issue, 6–40. Internal Paper. (2009). The Fourth Forum of directors of nursing homes for the aged. Ministry of Civil Affairs. (2008). Statistics of Ministry of Civil Affairs. Ministry of Civil Affairs, (2013), An interview. The internal document of Bureau of Civial Affiars of Shanghai (2012), Statistical information on the monitoring of the elderly population and the work of aging in Shanghai. p. 1. The Ageing Committee of Yuxi City, University of the Elderly in Yuxi. (2011). Infinite Digital Audio and Video production Center in Public Channel of Yuxi TV Station; “Yuxi, Happy elderly Class”. Zhou, J. (2011). The experience of Yuxi: In standardized Construction of Rural Association for the elderly. Social Work in China, 11, 38–39.

Chapter 12

Appendix: China’s Elderly Care Policy and Its Future Trends Haijun Cheng

Since 1999 when China entered aging society, the Chinese government has formulated new policies to promote the development of elderly care services. In 2013, the State Council promulgated “Guideline for Promoting the Development of Elderly Care Services” (State Council Document No. 2013 – 35) and subsequently issued more than 30 government documents, thus laying down the top-level design for China’s elderly care services. Those papers regulated responsibilities in elderly care for the government, the market, and the society, therefore providing policy basis for eliciting the enthusiasm and motivation of the society to develop elderly care services.

12.1  Reform of Key Policies Presently, China’s elderly care services account for a very limited percentage of the national economy and social development, only 9% of the country’s tertiary industry. Now, China’s economy is under downward pressure. Taking elderly care services as important steps in the adjusting process of the economy structure, promoting reform and benefiting civil welfares, the Chinese Government has issued new elderly care policies in the following five areas.

H. Cheng (*) Training Center of Ministry of Civil Affairs, Beijing Social Administration Vocational College, East Beijing, China e-mail: [email protected]

© Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3_12

233

234

H. Cheng

12.1.1  Reform of Company Registration System On March 1, 2014, China’s new Company Law was officially implemented. The Law abolishes the limit of minimum registered capital. Real cash collection is no longer a matter for industrial and commercial registration. In registering, the company does not need to submit verification report, or any fees. The registered capital is changed from real cash capital to registered capital. Companies, which have received business license, no longer receive various annual enterprise inspections. The simplification and reform of industrial and commercial registration system, to a large extent, facilitates the founding of companies, makes easy citizen’s entrepreneurship, stimulates citizen’s entrepreneurial enthusiasm, reduces company startup costs and lowers the minimum requirement for companies to enter business. This change mobilizes the market inner living and self-generated motivation. It helps to create a situation of “masses engaging in innovation and people starting up business.” Data released by the State Administration for Industry and Commerce shows that the average number of newly registered enterprises per day reached 10,300 after the implementation of the changed registration procedure in March 2014.

12.1.2  Policy Concerning Elderly Care Professionals In June 2014, nine ministries and commissions under the State Council jointly issued “Guideline on Accelerating the Training of Personnel Engaged in Elderly Care Services.” The guideline proposes a training system, which takes vocational education as the main body, integrated with practical-typed education at the undergraduate and graduate levels. It puts forward a paralleled education system comprising college education and vocational training for personnel in elderly care services. The guideline gives 12 concrete points of view on the training of personnel. (a) Increasing training specialties Training organizations set up such new specialties as elderly care and management, social work, health management, rehabilitation technique, use and service of rehabilitation auxiliary equipment, etc. (b) Education at college graduation level Colleges set up such elderly care related specialties as Rehabilitation Therapy, Nursing, Applied Psychology, and Social Work. (c) Education at postgraduate level Increasing master degree grading points related to social work specialty, encouraging and supporting qualified universities to enroll graduate students in Sociology, Gerontology, Demography, Rehabilitation Therapy, Family Development Science, etc., thus preparing professionals and high level teachers and researchers for elderly care research institutions and vocational schools and colleges. (d) Promoting the building of internship base (e) Speeding up the construction of elderly care related specialties

12  Appendix: China’s Elderly Care Policy and Its Future Trends

235

(f) Speeding up the compiling of elderly care related textbooks (g) Speeding up the training of teaching personnel in elderly care specialty (h) Promoting international exchange and cooperation (i) Improving the quality of personnel engaged in elderly care work (j) Carrying out “double credentials” policy in elderly care and related specialties, that is, granting of graduation diploma and “professional qualification certificate.” Encouraging students to obtain “professional qualification certificate” while acquiring graduation diploma. (k) Promoting volunteer service in the area of elderly care (l) Encouraging elderly care specialty graduates to work in elderly care organizations

12.1.3  Land Policy Concerning Elderly Care In April 2014, the Administration Office of the Ministry of Land and Resources issued “guideline on the use of land for elderly care facilities,” which aims to regulate the use of land for elderly care. (a) The use of land for elderly care facilities is marked as “For Medical and Welfare Use” when applying and registering for the use of land. The use of land for elderly care facilities is included in the overall plan for state owned construction. (b) Land applied by nonprofit elderly care service organizations will be supplied in the form of allocation. Land applied by profit elderly care service organizations will be supplied in the form of using for compensation, such as leasing or selling. Land applied by newly established elderly care organizations concerns new construction land, therefore, priority will be given to those organizations that have met the conditions set by the national land use plan and rural and urban planning in allocating quota when formulating the annual land use plan.

12.1.4  Financial Support Financial support is expressed in the following five areas: (a) Construction of home elderly care facilities, including daytime care center, canteen for elderly, elderly activity center, and elderly services information platform. (b) Construction of elderly services network, offering home care to help the elderly to eat, to bath, to clean, to help in emergency, and to provide medical aid. Those services cover a wide range of items from daily life care, health services, recreation activities, etc. (c) Construction of elderly care institutions, including home for the aged, social welfare institute, old age care institute, geracomium, community for the aged, etc.

236

H. Cheng

(d) Construction of training base for elderly care personnel, including the construction of related specialties in colleges, training of professionals, and training of related personnel. (e) Supporting business related to elderly care, which includes daily care, health care and products and equipments designed for the elderly.

12.1.5  On Incentive Policies Since 2013, a number of incentive policies have been carried out concerning investment of private capital in elderly care services. (a) Encouraging social capital to invest in the reform of public organizations, turning qualified training and health recover centers under the state owned units into elderly care institutions. (b) Encouraging social capital to invest in the construction of elderly care facilities, in the form of private management under public ownership, or private management with public aid, through the form of whole ownership, joint venture, cooperative management, joint management, or leasing. (c) Improving and completing incentive tax policies for nonprofit elderly care organizations. The construction of nonprofit organizations will be exempted from relevant administrative fees, and administrative charges for the construction of profit making organizations will be reduced by halve. (d) Elderly care organizations will pay electricity, water, and gas fees according to the charge rate for city residents. Public owned elderly care organizations collect service fees according to the price rate set by the government. Other organizations implement the policy of self-determined charge rate for its service items.

12.2  Characteristics of China’s Elderly Care Policy Since 2013, China’s elderly care policy has undergone a process of changing from concrete matters to overall planning, from involving a single department to concerning a number of departments, and from a lower level progress to a higher level development. The change shows three trends and five characteristics.

12.2.1  Three Trends Developing from concrete matters to overall planning, from involving a single department to concerning a number of departments, and from a lower level progress to a higher level development.

12  Appendix: China’s Elderly Care Policy and Its Future Trends

237

12.2.2  Five Characteristics (a) Overall Planning The elderly care policies carried out since 2013 have developed into a relative complete policy system, involving all important areas related to elderly care services, such as land use, commerce, training, public organizations, community, administrative examination and approval system, management, investment of foreign capital, integration of medical treatment and recover therapy, involvement of social capital, government purchase service, and standardization. (b) Authority All those policies have been worked out by the central government. They bear the authority to direct administration at the national level. Being policies of an administrative regulation nature issued by the highest administrative organization, they must be carried out by local management organizations. (c) Concreteness The elderly care policies carried out since 2013 are mainly “quantitative” policies dealing with concrete measures, which is different from the past habit of making qualitative analysis by using vague terms. (d) Integration Elderly care policies have been issued and carried out by a joint effort of many related departments, overcoming the disadvantage of administration by a single department. This form of issuing policy jointly has become an important characteristic. For example, nine ministries and commissions issued paper concerning training and ten ministries and commissions issued paper concerning investment private capital. (e) Innovation Most policies were issued for the first time. They were new in public.

12.3  Future Trends The elderly care policies carried out since 2013 greatly encouraged the development of elderly care services and adjusted the proportion of elderly care in the tertiary industry. In deepening elderly care reform in the future, the key areas concern clarifying responsibilities among the government, the market, and the society. The government should find its right position. Like the road traffic, the government functions as the road lamp and the traffic lights, but the government cannot play the role of a vehicle driver. There are four trends in the future: (a) Increasing employment to increase GDP (b) Carrying concrete measures to solve welfare treatment problems in personnel management (c) Pushing innovation of existing policies and working out of new policies through trying out by local pilot practice first (d) Reinforcing the monitoring of the elderly care market

Index

A Active aging, 66, 67, 111, 112 Active care, 106, 111, 112 Aging-friendly community, 63 Aging in no place, 66 Aging in place (AIP) American Association of Homes for the Aging, 64 Americans with Disabilities Act, 65 caregivers, 65 commercial providers, 65 demographers, 64 environments, 63, 65 housing development, 64 NORC, 64 older adults leverage, 65 public funding/government grants, 66 social support, 63 Aging policy, 73, 74, 106 Aging society, 214 Amenable mortality, 133 American Association of Homes for the Aging, 64 Americans with Disabilities Act, 65 B Bismarckian social insurance schemes, 74 Building a harmonious socialist society, 17 C Capability, 48, 49 Care for older people, 95, 101 Certified Aging in Place Specialists (CAPS), 64

Challenge Stalingrad turning point, 85 China’s elderly care policy characteristics, 237 company registration system, 234 financial support, 235 incentive policies, 236 national economy and social development, 233 training system, 234, 235 trends, 236, 237 use of land, 235 China’s social security system, 23 Chinese characteristics socialism, 15 Chinese Health and Retirement Longitudinal Study (CHARLS) caregivers, 172 the Chinese Family Development Report, 172 living arrangements of older people, 171 old age services, 171 social care services, 172 Chinese welfare system aging society, 21 characteristics cultural factors, 27 economic basis, 27 globalization, 27 people’s dominant position, 26 socialism, 26 coverage of social insurances, 21 dual social–economic system, 16 economic achievements, 20 economic reform, 17

© Springer Nature Switzerland AG 2019 T.-k. Jing et al. (eds.), Aging Welfare and Social Policy, International Perspectives on Aging 20, https://doi.org/10.1007/978-3-030-10895-3

239

240 Chinese welfare system (cont.) individual responsibility, 17 industrial primitive accumulation, 16 market-oriented organizations, 17 maternal and infant health services, 22 migrant workers, 21 people-oriented and comprehensive sustainable development, 17 people’s living standards, 21 polarization and poverty, 20 public expenditure, 18 residual welfare, 19 rural welfare policy, 16 social assistance, 17, 19 social insurances, 18, 19 socialist planned economic system, 16 social protection, 21 stages, 15 universalism, 16 welfare relief and services, 16 work unit, 16, 17 Cold era of social policy, 125 Collective welfare, 16 Collective-based social protection system, 36 Community advantages, 213 definition, 212 integrate resources, 212, 213, 220, 223 comprehensive social care services, 228, 229 economic and social, 230 government departments, 228 macro-policy guidance, 230 management structures, 228 material and financial, 229 single network platform, 230 social and market, 228 urban and rural areas, 228 life and cognitive range, 212 rural and urban situations, 212 service centres, 213 Starlight Old Age Plan, 213 Community care caregivers, 57, 58 historical forces, 56 personalization, 58 provision, care, 57 welfare pluralism, 57 welfarism, 57 Community services aging, 58 aging in place, 59 family support, 59 in Gansu Province

Index mutual help home (see Mutual help home) nursing homes (see Nursing home) social enterprises, 220 GPP, 60, 61 non-monetary provisions, 59 occupation-based system, 59 rural China, 61 in Shanghai Bureau of Civil Affairs, 219 catering, 216 colleges, 214, 215 entertainment room, 214 guidance center, 220 health interventions, 216 hospitals, 215 institutions, 217 mental health service, 215 nursing homes, 218 quasi-market mechanism, 216 service stations, 216 social welfare home, 217 social workers, 219 social control, 59 socioeconomic reforms, 58 strategic transfer, 60 urban community, 60 in Yunnan Province building aged centers, 226, 227 set up Aged Association, 227 University (see Yuxi University) Comparative historical analysis, 56, 58, 66 Compulsory education, 45 Consensual democracies, 10 Consensual governance, 9 Cultural walking stick, 111 D Decentralisation, 95, 96 Defamilisation, 99 Deinstitutionalisation, 97, 98 Demographic panic, 92, 97, 102 Digital Economy and Society Index (DESI), 127 Digitalization, 126–130, 132, 135 E Elderly care services co-payments, 107 cultural minorities, 108 female employment, 107 LTC, 107, 108 public financing, 108

Index public sector, 108 service universalism, 108 universal care model, 108 users, 107 Electronic client data systems, 127 Employment structure, 32 Empowerment, 112 Enabling environment, 48 Equality, 8, 9 e-Services, 126 Esping-Andersen’s typology, 4 Europeanization, 12 European Union (EU), 128 e-Welfare and e-Health in Finland client records, 128, 135 customer data in social welfare and healthcare, 129 electronic patient records, 135 experiences digitalization of social assistance (see Social assistance) ICT-systems and applications, 129 policy goals, 126 (see also Policy level) social and health care sectors, 129 strategic goals, 128 F Finland’s on-going social and health care reform, 135 Finnish Open Data Programme, 135 Free choice of Provider Scheme, 113 Freudian theory, 62 G Gender equality paradox, 110 General public policy (GPP), 60, 61 Gini coefficient of China (1997–2014), 20 Global AgeWatch Index, 48, 49 Government expenditure, 45–47 Gross national product (GNP), 126 H Harmonious society, 39 Healthcare policies, 40 Health status, 48, 49 I Income security, 48, 49 Independent living, 112

241 Information and communication technologies (ICT), 126 Innovations in care, 110, 112 ageing population, 118 functional abilities, 118 labour power, 119 labour saving effect, 119, 120 non-mature technologies, 119 permanent austerity, 118 quality of care, 120 welfare technology, 118 Institutional Welfare State social administration and policy arena, 77–79 International economic development, 11–12 Intra-organizational electronic services, 133 Intrinsic system construction, 155, 161 J Japan’s social spending, 48 K Kanta amenable mortality, 133 cooperation vs. healthcare services, 133 cooperation vs. physicians, 133 electronic patient record, 133 intra-organizational electronic services, 133 national data system, 132 national-level electronic survey, 132 patient online service, 132 public primary care, 133 renew prescriptions, 132 SosKanta system, 128 L Law on Compulsory Education, 45 Life expectancy, 105 Local authority funded care services, 94 Long-term care (LTC), 62, 106 in Finland age structure, 92–95 decentralisation, 95, 96 deinstitutionalisation, 97, 98 demographic panic, 92 marketisation, 100, 101 Nordic welfare model, 91 overarching motivation, 102 recentralisation, 96, 97, 102 refamilisation, 99, 100

242 Long-term care (LTC) (cont.) residential provisions, 101 social and health care services, 92 tax rebate scheme, 92 Lubben Social Network Scale (LSNS), 62 M Marketization, 100, 101, 113, 117, 121 Migrant workers, 37 Ministry of Civil Affairs of China, 22 Mutual assistances, 45 Mutual help home advantages, 223 Bureau of Civil Affairs, 223 Council of Aged Association, 224 inside and outside services, 224 principles of building, 222 self-management, 224 twinning services, 225 welfare lottery fund, 223 N National Association for Public Health, 109 National associations of home builders (NAOHB), 64 National Audit Office of Finland, 97 National Bureau of Statistics (NBS), 34 National data system service, 127 National Health Service and Community Care Act of 1990, 58 National-level electronic survey, 132 National Organization of Pensioners, 85 National People’s Congress (NPC), 44 Nation-building project, 7 Naturally occurring retirement communities (NORC), 64 Negative parliamentarism, 10 Neo-liberalism, 12, 78 Network evolution, 174, 176 Network mapping, 179 Network transition bureaucratic-style network, 188 description, 176 government employees, 189–191 government sponsorship, 191–193 history of, 180 people’s services system, 188 SOs, 188–191 Non-government organisations (NGOs), 193, 195 Non-socialist government, 112

Index Nordic characteristics, 4 Nordic cooperation, 10, 11 Nordic welfare model, 91, 96, 101 ambiguous attitude, 5 authoritarian/totalitarian systems, 5 conceptions, 5 cooperation, 10, 11 embryonic development, 5 equality, 8, 9 financial crisis, 5 forms of governance class/economic interests, 9 conflict resolution, 9 consensual governance, 9 consensus-making, 10 employers’ associations, 9 minority coalition governments, 10 social reforms, 10 sustainable political decisions, 10 trade union federations, 9 ideologies, 5 market-oriented welfare democracies, 6 middle way, 5 neo-corporatist system, 5 normative connotations, 5 social and political stability, 11 stateness, 7 universalism, 7, 8 Norwegian Gerontological Society, 109 Nursing home categories, 221 local government’s investment, 221 preferential incentives, 221 set up, 221 tax relief policy, 222 O Old age care, 169–171, 173, 174, 180, 181, 185, 195–198, 203, 204 Old age dependency ratio (OADR), 105 Old age services, 181, 183, 184 CHARLS (see Chinese Health and Retirement Longitudinal Study (CHARLS)) complexity, 173, 174 data collection, 178, 179 research, 178, 179 Organisation for Economic Co-operation and Development (OECD), 128 Organization of social and health care services, 125

Index P Pension programmes, 8 People-centered development, 26 Personalization, 58 Policy actors, 106 Policy ideas, 106 Policy level digitalization challenges, 127 electronic client data systems, 127 electronic data management, 127 Kanta health care system, 128 social assistance system, 128 Policy-making, 102 Political philosophy, 146, 162, 163 Population ageing, 92, 93, 97, 120 Public health services, 41 Public policy, 63, 64 Public responsibility, 120 Public revolution, 120 Public services, 126 Public Welfare Project bidding, 219 Publicly funded services, 126 R Rainbow Coalition government, 9 Rambøll management, 119 Recentralisation, 96, 97 Refamilisation, 99, 100 Republic of Korea, 48 Rural labor force, 37, 38 Rural surplus labor force, 33 S Scandinavian model, 6 Self-employment, 37 Service housing, 95, 98 Service system, old people policy making, 212 practical demands, 211 service shortfalls, 213 surveys, 211 Sharing, 31, 40 Social assistance, 45 applications, 130 components, 130 Kela benefit, 130, 131 ICT-systems, 131, 132 telephone services, 131 Kelmu ICT-system, 131 legal framework and instructions, 131

243 making decisions, 132, 134 resort income benefit, 135 supplementary and preventive, 130, 132 Social assistance system, 19 Social democratization, 77 Social equity, 39, 40 Social insurance system, 3, 18, 19 Social organisations (SOs) in community, 186–189 network-ness, 196, 197 social workers, 189–191 users, 195 Social policy, 39 Social protection policies, China education, 42, 43 family and child benefits, 43 funding responsibility and channels, 45 government expenditure, 45–47 healthcare policies, 40 housing protection, 42 Law on Labor Contracts, 42 legal effects, 44 old-age insurance and services, pension scheme, 41, 49 poverty alleviation, 43, 44 protection and sustainability, 44 public health services, 41 scope and extent, benefit, 47 social assistance, 48 social organization mechanism, 50 social services, 44, 50 unemployment insurance, 42 unemployment protection, 41 unit-based social protection system, 47 Social protection system, China commercial old-age insurance, 39 interregional gaps, 40, 50 migrant workers, growth, 38 new system vs. previous system, 38 policies, 49 reform and opening up, 36 rural education, development, 36 rural labor force, 37 security net, 35 self-employment, 37 social and economic development, 40 social equity, 39 social policy, 39 social security, 39 social self-protection system, 40 social spending, 37 state-owned enterprises, 38 taxation, 38

244 Social protection system, China (cont.) three-tier healthcare system, 36 trial-and-error process, 38 urban-rural gaps, 40, 50 urban unemployment, 39 Social risk, China aging population, 35 employment structure, 32 Gini coefficient, 32, 33 income gap, 32 NBS, 34 old-age dependency ratio, 35 post-industrial society, 32 poverty alleviation, 32, 33 poverty incidence, 33 rural poor population, 33 social and economic development, 35 unemployed population, 34 unemployment rate, 34 urban-rural income ratio, 32 Social security system, 7, 17, 19, 126 Social self-protection system, 40 Social service, old people advantages, 213 categories, 220 community, 212 guidance center, 220 medical care, 213 nursing homes, 218 nursing staff, 217 professional social work organizations, 218 professional social workers, 218, 219 public institutions, 217, 218 Social spending, 37 Social support aging-friendly community, 63 LSNS, 62, 63 service locations, 63 stress-related disorders, 62 Social union, 6 Societyness, 77 Starlight Old Age Plan, 213 Stateness, 7, 77 State-owned enterprises, 47 Strategic transfer, 60 Stress-buffering, 62 Superficial system construction, 155, 161, 162, 164 Sweden mass consumption, 86–89 retirement pensions and personal health, 79–84 social services and housing, 79–84

Index territory, demography and economy, 74–77 voluntary civil society associations, 84–86 Swedish pensioner’s association, 85 System construction central government, 153 development direction, 149 elderly, 155 era of modern welfare, 142 intrinsic, 155, 161 market economic, 145 non-functional, 161, 164 old-age service of China, 156 policies and regulations, 155, 159 public administration, 159 quality of, 145, 146, 155, 156, 162 social insurance, 143 superficial, 155, 161 T Taxation, 7, 38 Tax financed system, 120 Three-tier healthcare system, 36 Trial-and-error process, 38 21st century ageing welfare and social policy, 73, 74 U Unemployment insurance, 8, 42 Unemployment protection, 41 Unit-based social protection system, 36 Universalism welfare system, 7, 8 cash security, 23 laws and regulations, 25 people-centered approach, 24 people’s livelihood, 24 service groups, 22 social and economic development, 23 social construction and management, 25, 26 social expenditure, 24, 25 social insurances, 23 socialism, 23 social welfare, 24 sustainable development, 23 welfare measure, 23 Urban communities in China in caring system, 184–186 characteristics of old age services, 171 CHARLS (see Chinese Health and Retirement Longitudinal Study (CHARLS)) family care and state support, 180, 181

Index local governments, 204 Ministry of Civil Affairs, 197, 198 multi-dimensional transformation, 203 network evolution and transition, 174, 176, 177, 180 network-ness, 205 network stability, 177, 178 network transition (see Network transition) prescriptive and paternalistic, 170 privately funded care services, 197 professional social work, 205 Shanghai Social Welfare Association, 198–202 social needs, 170 social organisations, 186–188 social services, 197 stakeholders, 170 the 2013 Human Development Report of China, 169 the 2015 Social Service Development Statistical Communique, 169 Xiamen City and Taicang in Jiangsu, 202, 203 Urban welfare system, 16 V Vossamodellen, 112 W Washington consensus, 12 Welfare mix, 106 civil society actors, 113 co-creation, 118 economic independence, 109 elderly care service area, 108 financing, 112, 118 home care services, 117 marketization, 113, 117 organizations, 109 poverty policy, 108 public opinion, 117 publicly financed services, 117 voluntary sector, 117 Welfare models, see Nordic welfare model Welfare municipality, 110 Welfare pluralism, 57, 60

245 Welfare policies for the elderly in China analytical framework, 148 central government, 149 Chinese Communist Party and Central Military Commission, 147 construction process and development track, 154 developments and changes, 150–152 development stages and characteristics, 141, 142, 144–147 history of, 148 ministry/commission of the State Council, 154 National Working Commission on Aging, 153 old-age service policies, 164 political issues and social problems, 163 Protection of Rights and Interests, 149 provincial and sub-provincial governments, 148 service system framework, 164 structural defects and systematic insufficiency, 155–161, 163 Welfare states ageing of the population, 12 conceptualizations, 4 corporatist-statist/conservative regime, 4 cultures, 4 democratic/authoritarian, 3 family policies, 12 globalization, 11 immigration, 12 individual responsibility, 12 political-economic systems, 4 privatization, 12 social democratic, 4 societal transformations, 3 systems of governance, 4 Welfare technology, 106, 120, 121 Welfarism, 57, 60 Y Yuxi University Department of Lantern, 226 geriatric education, 226 health course, 225 teaching, 226