By Samuel Green

In the previous articles (Part I is HERE, and Part II is HERE) we introduced the problems an elderly person in rural China will face on an individual level. How migration affects their psychological well-being and how they receive care. In this section we will discuss the more macro-level issues of human healthcare resource disparities and the hukou system. We will also look at the fledgling baomu initiative which may address some of the issues faced by the rural elderly.

One issue that has not been discussed extensively in academic literature is the impact of migration on the ‘brain drain’ experienced in rural China. China is a perfect example of problems faced in every healthcare system. Rural areas find it difficult not only to properly train medical practitioners, but to keep them from migrating to urban areas. As discussed previously, the aging rural population will require more health resources. As the rural population ages it will require more chronic treatment, not covered by the NCMS. However, trained doctors still continue to flock towards urban areas which already have sufficient resources. While the brain drain has been significantly studied and discussed, there has been little research on the attitudes of urban doctors towards working in a rural area. Many articles have suggested that urban doctors should be forced to work in rural areas to alleviate the strain on resources.

This solution would increase the ability of rural services to provide high technological care (Dib et al., 2008). A number of levels of government are attempting to encourage experienced specialists to switch from hospitals to work regularly at community based services, since their skills and expertise valuable towards the improvement of care (Liu, 2006). Incentives need to be created for doctors to move to/stay in rural areas (Anand et al., 2008). But, rural areas are inconvenient, lower paid and lack the prestige and status one achieves when practicing in the city. As the average Chinese youth becomes more and more educated, the average age of certified doctors is likely to decrease. On the other hand, rural areas are populated mainly by the elderly. As young people leave the countryside to head for the city, the social incentives of doctors to practice in a rural area will likely diminish. A city like Shanghai influences a completely different lifestyle to that of Chaohu. Will Shanghainese doctors want to work in Chaohu? Probably not.

Even though the ‘barefoot doctor’ of the past appears to have disappeared (Zhang & Unschuld, 2008), the benefits gained from expert training and delivery would be much appreciated in this new scheme. Dummer & Cook (2007) also recommend a new barefoot doctor scheme, with a focus on primary preventative care.

It should also be said that if China figures out how to get good doctors to the country side then it will be somewhat of a global hero, since almost all countries have this problem.  An additional vital question that needs to be asked, which is more unique to China,  is whether the upcoming health care crisis for the elderly in rural China is caused by migration, or if migration just exacerbates underlying problems that already existed.

While one might simply point at the above discussed  brain drain the real culprit might be the hukou system. The hukou system is a household registration system which, among other things, is used to calculate health insurance requirements and analyze the needs of the local population. Rural-urban migrants are not registered in the hukou system. Thus they are not included in urban health insurance schemes and are ignored when making resource allocation decisions. Health policy is based solely on the local registered population.

“In many towns along China’s coast and particularly in the Pearl River delta, migrants outnumber the local population by large margins, but they are very rarely mentioned in local government development plans and reports. All social and economic development indicators, such as the school enrolment rate and number of hospitals for every thousand persons, are calculated on the basis of the size of the permanent population.” - Biao (2007)

the children of migrant's cannot go to schools in areas where their parents aren't registered

Migrants are left in an extremely vulnerable position, one where social benefits are non-existent and job security is low. This is the primary reason why rural family members are left behind, because dependants would not receive any benefits of migrating. It is much more efficient for the breadwinner to send money back to their home-town (where prices are cheaper and there is some form of social welfare) than to move the whole family to an urban area. However this means there is a need for a caregiver to replace the missing child. This is the fundamental institutional problem behind the lack of caregivers.

The concept of a ‘baomu’ (literally, Protection Mother) is becoming more popular in families that can afford it (600-1000RMB/month). Essentially a live-in maid, a baomu has basic knowledge of eldercare (Cooke, 2006). Of course, a fundamental problem of the baomu system is that the employed maid will have less time to care for their own relatives. There is also a need for quality standards. It is unlikely that the baomu supply on its current trajectory will keep up with the rapid increase in the elderly population, but it is essential that these services are in place to ease the strain on nursing homes. One solution would be to encourage private sector investment in eldercare. It is a growing segment (over 500% projected) and there is considerable need for a baomu system that has standards and can allocate resources efficiently.

This report by the Beijing Review is worthwhile reading; ‘Aging City Leads the Way‘.although it is difficult to predict whether this sort of system would work in a rural area, as many of the potential baomu would have left for the city. The government is encouraging private initiatives in the nursing home sector but, in Beijing for example, the system currently only serves 0.6% of the senior population (Xinhua News Agency, 2005). This is woefully inadequate, and Zhang (2000) highlights that to increase capacity by just 3% the government would have to invest at least US$200 billion (based on numbers from the Ministry of Civil Affairs).

Holistically this series has discussed the major issues of rural-urban migration on the elderly left behind. In the final part we will suggest ways to improve the system and conclude whether it is too little too late, or if a crisis situation can be averted.