Table 3 Systematic review findings for Chinese Long-Term Care of older people.

Bao, J., et al. (2022). BioScience Trends. [106]

Review of smart old age care in China.

• “Internet + model” integrates online and offline old age HCBS resources.

• Challenges: personal privacy at risk due to use of “big data”, older adults less adept at using digital technology.

• Develop applications that are suited to older adults’ usage.

• Enhance management and safety of big data.

Chang, C., et al. (2021). Chinese Social Security Review. [107]

Analysis of policy texts on LTC for older people with disabilities and dementia, published by the State Council from 2011 to 2019.

• National policy documents confuse LTC and concept of filial piety.

• Fragmentation of LTC management horizontally between government departments and vertically from national to local level.

• Unmatched LTC supply vs. demand.

• Clarify LTC policy aims and responsibilities for the state, market, family and individuals.

• Improve governance.

• Policies to harmonise supply vs. demand.

Chen, H. & Ning, J. (2022). Health Policy & Planning. [108]

Quasi-experimental study of LTCI on health utilisation and out-of-pocket health expenditure, using data from CHARLS 2011, 2013, 2015, 2018.

• LTCI significantly reduced inpatient out-of-pocket cost by >500 yuan but not outpatient costs.

• No. of outpatient visits, inpatient stays and hospitalisations significantly reduced.

• LTCI coverage should be expanded to reduce out of pocket costs.

Chen Y., et al. (2022). Health Economics Research. [109]

Review of 29 LTCI pilot cities.

• Narrow coverage of LTCI.

• Multi-channel funding and poor financial sustainability.

• Third-party assessments encouraged but often biased.

• High integration costs because of fragmentation.

• Principles for development of high-quality LTCI: equality and adequacy.

• Collaborate all responsible parties.

• Improve LTC service supply capacity.

Du, P., et al. (2021).

Research on Aging. [110]

Literature review of government reports, academic databases and reports from international organisations from 2000 to 2019.

• Poor connectivity between regions for service eligibility, funding sources, insurance, management, benefits, subsidies, care costs.

• Rural-urban disparities in access.

• LTC needs assessment excludes mild and moderate CI and FI.

• Preferences for care are family-based.

• LTCI coverage is narrow: most areas only cover medical care.

• Underutilisation of HCBS (estimated at <10%).

• Increase integration between urban and rural areas.

• ‘Person-centred’ care: ensure policies meet LTC needs of all populations.

• Consider role of family combined with institutional care.

• Extend LTCI coverage.

• Use public-private partnerships to link HCBS resources.

Du T., et al. (2022).

Health Economics Research. [111]

Analysis of policy texts of 29 LTCI pilot cities.

• Main sources of LTCI funding: individuals, employers, basic medical insurance.

• A trend towards employer funding instead of basic medical insurance among urban workers.

• Relying on health insurance is not conducive to a sustainable funding system.

• Setting funding standards to local economic development is not conducive to formation of a national funding framework.

• LTCI predominantly funded on a flat-rate basis; mechanism for dynamic adjustment of rates is missing.

• Funding responsibilities should be reasonably divided.

• Move towards proportional funding and establishment of funding criteria to guarantee basic benefits.

• Establish a dynamic rate adjustment mechanism.

Fang, E.F., et al. (2020). Ageing Research Reviews. [112]

Review of ageing in China, including long-term care policy.

• Needs assessments tend to be one-off and disconnected to care plans making it hard to allocate appropriate resources.

• Investment predominantly in nursing homes resulting in an oversupply of care beds and lack of HCBS. 45% of nursing home beds unoccupied.

• Most LTCI schemes are based on social health insurance with different eligibility criteria and benefits packages.

• Care needs should be subject to regular reassessment.

• Assessment should include multi-dimensional health status.

• Education and training of integrated care managers to coordinate services across public and private sectors.

• Link personal health records, assessments of older peoples’ care needs and care costs to integrate data.

• Direct more attention to disabled elderly, low socioeconomic status, no family support.

Feng, Z & Glinksaya, E. (2021). China: An International Journal. [113]

• Service quality depends on ability to pay.

• Only ≥80 year old age groups are eligible for services in some pilots.

• Government invests more in LTC facility construction, beds and subsidising operational costs than cash allowances and consumer service vouchers.

• Common feature of all pilots is building on medical insurance programmes.

• Ningbo and Guangzhou raise funds solely from UEBMI pooled funds, don’t add individual or employer contributions.

• In Changchun, cancer patients can also be eligible for LTCI benefits. Mental illness is not routinely included.

• Shanghai is only pilot that specifically sets a minimum age for receiving LTCI benefits, at 60 years old.

• Shanghai offers option of either cash or service benefits.

• LTCI fundraising standards should be determined by local need and conditions.

• LTCI should not pay for services that are already covered under other existing social insurance systems and avoid duplicate coverage of benefits for the insured.

• Government should partner with private-sector enterprises that are qualified to perform disability and needs assessments.

Gruat, J.V. & Chuan, S. (2021).

International Social Security Review. [114]

Review of pilot schemes in Qingdao, Changchun, Nantong, Shangrao, Jingmen, Shanghai.

• ~90 million participants, 430,000 service providers, 77% coverage across all pilot schemes.

• Health insurance is main funding source, excluding poorer groups who lack cover.

• Regional differences in funding, eligibility, services, trained staff, infrastructure.

• Beneficiary satisfaction is 82% in western regions vs 69% in eastern regions.

• Dependency insurance should be autonomous social insurance, not part of health insurance.

• Costs incurred by beneficiaries should be covered at 70%, to increase access and reduce inequality.

• Harmonise regional resource allocation and service delivery.

Han, y. & Shen, T. (2022). International Journal of Environmental Research and Public Health. [115]

Semi-structured interviews with 10 beneficiaries and providers of LTCI in nursing homes and 2 operators at the Medical Insurance Bureau in 4 pilots, Qiqihar, Changchun, Tonghua and Panjin, in North-eastern China.

• Subsidies and policy support are vague for care providers.

• Service providers vary across pilots.

• 70 years olds unwilling to accept HCBS.

• State abolished nursing caregiver qualifications in 2021.

• No centralised management of HCBS, difficult to recruit staff to in-home services, more attention paid to institutional care.

• When disability levels change, nursing levels cannot be dynamically adjusted and so wastes resources.

• LTCI coverage is restricted by medical insurance.

• Greater public health expenses due to COVID-19 has brought pressure on medical insurance funds and affected fundraising of LTCI.

• Provide cash subsidies or welfare payments and regular professional training to family caregivers.

• Form a nationwide, interconnected information database for services.

• Dynamic health monitoring to explore LTC needs of disabled and dementia groups to match supply and demand.

• Government should increase financial subsidies for less developed regions.

• Incorporate LTCI policies with overall economic and social policies.

He, Y.H., et al. (2021). Chinese Journal of Social Medicine. [116]

Policy analysis of 15 pilot cities: Guangzhou, Ningbo, Chongqing, Anqing, Chengde, Shangrao, Qiqihar, Chengdu, Shanghai, Qingdao, Suzhou, Nantong, Jingmen, Shihezi, Changchun.

• LTCI has a low reimbursement rate, most between 70–80%, which affects the appeal of LTCI.

• Develop LTCI through diversified financing.

• Increase LTCI benefits to compensate for low reimbursement, in the form of subsidised services.

Hu, H.W., et al. (2021). Social Security Studies. [117]

Systematic review of the financing framework for care of rural-disabled elderly in China.

• Declining role of family in financing for rural-disability care.

• Network of responsibility for financing: government finances basic care services; village collective or mutual aid organisation is pension fundraiser; society and market play a supplementary role.

• Strengthen network and clarify responsibilities for financing: harmonise, training and resource allocation.

Huang, Y.X., et al. (2021). Journal of Nursing Science. [118]

Review of home care services under LTCI systems in China, Japan, Germany and the USA.

• Demand for social LTCI is greater than commercial LTCI in China.

• Demand for LTCI in western China is greater than in eastern and central China.

• Lack of community elderly care services in western China and elderly access to LTCI.

• Reform existing social insurance system e.g. set up independent LTCI fund.

• Improve community elderly care services in western China.

• Increase public awareness of LTCI.

Jing, G., et al. (2021).

Journal of Risk Analysis and Crisis Response. [119]

Literature review of Shanghai LTCI pilot. Forecasting model using data from individuals ≥60 years old in 2004–2017.

• Participants in LTCI pilot: 234,000 (2018) and 493,000 (2019).

• Population ≥60 years old receiving nursing services: 5% (2018) and 10% (2019).

• Shortage of nurses, low salaries, few nursing institutions, exacerbated by COVID-19.

• High unmet need.

• Increase the number of people receiving care. Increase nursing salaries and training.

Li X. (2021)

Shandong Social Sciences. [120]

Policy Simulation Analysis using data from CHARLS, 2011–2015.

• LTCI with an hourly subsidy and urban-rural coordination mechanism provides more stable risk protection than a flat-rate subsidy.

• Strong demand for LTCI.

• Integrate an urban-rural financing approach.

• Funding from multiple insurance mechanisms is more in line with characteristics of China's elderly.

Liu, H., et al. (2021). European Journal of Ageing. [121]

Cross-sectional study conducted in August 2017. Interviews with 6997 adults aged ≥ 60 years-old in Shandong province.

• Age, education, socioeconomic status, regional distribution, ADLs, loneliness had significant associations with preferences for LTC: family-based care (89%), institutional care (8%) and HCBS (3%).

• Most participants knew nothing about HCBS.

• Consider preferences for LTC.

• Improve quality of family care.

• Increase older adults’ awareness of HCBS.

Liu, H. & Hu, T. (2022). Archives of Public Health. [122]

Difference-in-differences (DID) method for LTCI policy using survey data from CHARLS 2013, 2015 and 2018.

• Number of hospitalization days significantly reduced; self-rated health improved among older adults.

• Monthly outpatient reimbursement expenses and annual inpatient reimbursement expenses increased by >4000 yuan/year for older adults.

• Most pilots only protect severely disabled who have a higher coverage in overall funding.

• LTC services ignore needs of rural disabled and do not have service capacity in rural areas.

• Address needs of moderately disabled individuals.

• Improve supply of LTC services in rural areas.

Liu Z., et al. (2022).

Medicine and Society. [123]

Literature review of 29 LTCI pilot cities.

• Inconsistent eligibility criteria.

• Assessment tools are dominated by single-type indicators and lack comprehensive assessments.

• Shortage of assessment agencies and assessors, process lacks effective management.

• Develop a comprehensive LTCI assessment tool.

• Improve professional standards of assessment agencies and caregivers.

• Strengthen supervision and management of assessment process.

Lu, B., et al. (2020). China Economic Review. [124]

Cost evaluation of Qingdao LTCI pilot using data from recipients who entered the programme in 2015.

• Successfully integrated LTC model.

• Reduced social hospitalisation: probability of using in-patient services declined by 12%.

• Increased LTC service spending offset by decreased inpatient services spending; overall decline by >10,000 RMB (1500 US$, 1200 GBP).

• Eligibility dependent on ADL score <60 and a diagnosed medical condition.

• LTC optimises resource allocation and alleviates hospital overcrowding.

• LTCI provides cost-efficient care for the disabled by reducing out of pocket expenses.

• Expand eligibility for mild and moderate conditions to increase access.

Luo J., et al. (2022)

Medicine and Society. [125]

Survey of senior citizens in Shanghai covered by LTCI.

• Overall LTCI satisfaction higher in Shanghai than other pilots.

• The higher the medical expenses, the lower the satisfaction with LTCI.

• Older people would like longer service hours.

• Provide more medical care for older people with higher medical expenses.

• Reasonable extension of the length of care.

Peng, R. et al. (2022). International Journal of Environmental Research and Public Health. [126]

Review and coupling coordination model of LTCI policy documents issued by the General Office of the Chinese People’s Government and Human Resources and Social Security Bureaus of pilot cities.

• All pilots cover UEBMI; some expanded to URRBMI.

• Most cover institutional and home care – Changchun and Ningbo only cover institutional care.

• Shanghai, Qingdao, Nantong have highest policy strength and coordination, in line with local economic development and population structure.

• Broad coverage of LTCI should be adopted to improve equity and accessibility of care.

• Other cities should study Shanghai’s LTC policy.

• Local government should determine the level of LTCI funding based on local economic development.

Peng, R., & Wu, B. (2021).

Research on Aging. [127]

System dynamics simulation and policy scenario modelling for adults aged ≥60 with at least one ADL, from 2015 to 2035.

• Low capacity of community-based care for disabled older people, especially in rural areas.

• Increasing LTCI compensation and capacity of institutional and community-based care would decrease % of disabled old adults cared for by family members from 93% (2015) to 64% (2035).

• Adjust resource allocation between institutions and community.

• Policies should balance family caregiving burden and LTC expenditures.

Shu Z., et al. (2022).

Population and Development. [128]

Cohort study using CLHLS 2014 and 2018 data.

• LTCI can "squeeze out” family financial support.

• LTCI plays a positive role in intergenerational relationships.

• Provide family caregiver support policies.

• Promote synergies between LTCI governance and social protection systems.

Sun, Y.X., et al. (2021).

Chinese Nursing Research. [129]

Review of LTC models in the USA, Japan and China.

• No unified standard for disability assessment and grading; ADL scale mostly used.

• Different needs among old age groups are not paid attention to.

• Multi-dimensional disability assessment system should be built.

Tang W., et al. (2021).

Journal of Finance and Economics. [130]

Cohort study using four waves of CLHLS data from 2008 to 2018.

• LTCI contribution rate from employees higher than that of residents.

• Form a LTCI pay-as-you-go system.

• Make residential care at low cost, which is under the greatest funding pressure.

Tang, Y., et al. (2022). Frontiers in Public Health. [131]

DID method evaluating LTCI using data from CHARLS, 2011, 2015 and 2018.

• LTCI reduced number of outpatients and inpatients by 0.2 and 0.1 per year.

• LTCI cut outpatient and inpatient expenses by 24% and 20% per year.

• LTCI improved self-rated health and ADLs.

• Integrate grading diagnosis and treatment with LTCI to match medical and nursing systems.

• Improve training of care service teams.

Wang, B. & Xu, L. (2022). Journal of Healthcare Engineering. [132]

Review of “Internet Plus” community smart care service platform.

• Uses big data and smart mobile devices to monitor older people in real time.

• Allows community centres to provide timely and accurate information for older adults’ service needs.

• Low willingness of older adults to accept, privacy leakage issues.

• Industry service standards have not been developed.

• Connectivity and integration of resources is weak due to service fragmentation.

• Government policies should integrate smart elderly services and collaborate service providers.

• Improve elderly technological literacy.

• Increase efforts to promote positive role of technology.

• Develop easy-to-operate platforms.

• Reward and punishment mechanisms to incentivise providers to prioritise care quality.

Wang, K., et al. (2021).

International Journal of Health Planning and Management. [133]

Content analysis of 12 major Chinese news portals in 2018.

• Most frequently identified LTC issue: few qualified professionals (47%).

• Few service types, low quality services, poorly integrated care, unstable LTC economic model e.g. for private investors, poor public understanding, organisational fragmentation.

• Private investors should evaluate their ability to recruit and train care staff, integrate care and expand profit patterns in HCBS.

• Government should formulate policies for private investors and promote public awareness of HCBS.

Wang, Q., et al. (2021).

Social Science and Medicine. [134]

Discrete choice experiment with 1067 community residents in Shenyang and Dalian, Liaoning province.

• Strong preferences for LTCI.

• Factors driving preferences: coverage ceiling, HBCS reimbursement, individual premiums.

• Poor coverage of complex daily assistance packages (home environment adaptation, dementia care).

• Consider how to increase attractiveness and sustainability of LTCI.

Wang, C., et al. (2022). Frontiers in Psychology. [135]

3513 questionnaires from older Chinese adults in 7 LTCI pilot cities.

• Older adults living with children are 20% less likely to choose nursing homes than those living alone.

• Male older adults are 30% less likely to choose nursing homes.

• Older adults with more hospitalisations more likely to choose nursing homecare.

• Those with greater monthly income, higher education level or a nursing home nearby are more willing to choose nursing home care.

• Insured older adults are 1.5x more likely to choose nursing home care.

• Expand LTCI coverage.

• Integrate interdisciplinary professionals in nursing homes to provide high-quality services.

• Promote medical services in nursing homes.

• Locate nursing homes in communities.

• Improve design of nursing homes to create sense of homeliness.

Wei, Y., & Zhang, L., (2020).

International Journal of Environmental Research and Public Health. [136]

Questionnaire surveys with 3260 elderly people aged ≥60 in six districts of Xiamen province.

• 82% chose home-based care, 13% chose institutional care with integrated nursing and medical services (up from 3% in 2013), 5% chose community-based care.

• Older age, higher education level, living in rural areas, better economic status, those cared for by others (other than spouses) are more willing to accept integrated services.

• Consider needs of different demographics.

• Strengthen family care and integrated care policies.

• Improve awareness of integrated care.

• Encourage implementation of integrated care in rural areas.

Wu, B., et al. (2021).

Research on Aging. [137]

Literature review of 6 recently peer-reviewed articles (2020) addressing issues related to LTC in China.

• COVID-19: reduced quality of community-based care, patients delayed moving into institutions, increased operational costs, stretched funding for LTC, high staff turnover rates.

• Social isolation common for disabled older adults but many lack knowledge of and access to mobile technology.

• Regulate community-based care.

• Improve LTCI benefits for disabled older people.

• Increase wages to retain and attract staff.

• Improve access to mobile technology.

• Develop person-centred applications with input from older adults.

Yang, W., et al. (2021).

Research on Aging. [138]

Qingdao pilot: analysis of 47 qualitative interviews conducted in 2016 with government officials, care providers and family members of service users.

• Eligibility excludes people with mild and moderate cognitive impairment.

• Poor public awareness of eligibility and service entitlement leads to unequal and unfair treatment.

• LTCI funds mostly from social health insurance means there are different benefits for those with same needs.

• Disparities in financial burden: poorer service users likely to incur high co-payments.

• Widen eligibility to include those with moderate cognitive impairment.

• Funding needs of low socioeconomic groups.

• Improve accessibility of information on entitlement and eligibility.

• Consider mandatory premium contributions.

Yang Y., et al. (2022).

Chinese Journal of Health Policy. [139]

Policy analysis.

• China's LTC policy does not align with the service system.

• Establish independent LTCI financing.

• Consolidate and use resources already available to fund LTC.

Zhang, Q., et al. (2020). BMC Geriatrics. [140]

Review of China’s policies on smart home elderly care.

• Smart care is policy-driven, not-demand driven.

• Older adults have little interest or understanding.

• Most older people regard smart care as a welfare product whereas providers want to make a profit.

• No industry standards or national regulation.

• Multiple government departments are jointly responsible for supervision.

• Explore older adults’ willingness to use smart care

• Form technical standards.

• Combine existing public and private smart home platforms to optimise resource allocation and management.

• Encourage development of new technologies to reduce cost of products and make smart care accessible and acceptable for older people.

Zhang, L. (2021). Frontiers in Public Health. [141]

System dynamics model of LTCI financing system using data from Xiamen Special Economic Zone Yearbook and field study.

• Without any intervention, revenue and expenditure of LTCI funds from 2020 to 2030 will increase year on year by 3.7 times and 8.8 times, respectively.

• After 2029, expenditure > revenue amounting in an LTCI deficit.

• Highlights urgency of improving LTCI financing system and establishing a unified LTCI financing mechanism.

• Increasing the individual payment rate can delay deficit.

• Increasing government financial subsidies and enterprise contribution rates can prevent deficit.

• Implement a paying policy for urban retired employees which can increase revenue of LTCI funds and maintain its stability and improve fairness.

• Share funding responsibilities between individuals, enterprises, government.

Zhang, Z.Y., et al. (2021). Chinese Health Service Management. [142]

Policy analysis: integration of medical and care services between the 13th Five-Year Plan (2016-20) and the 14th Five-Year Plan (2021-25).

• Needs assessments exclude many requiring care and don’t consider financial care burden.

• Management of integrated care fragmented and inefficient.

• Form a hierarchical assessment of needs and link this to charging standards and service supply of institutions and HCBS.

• Establish a big data platform for health management of older people.

Zhang, Q., et al. (2020).

Healthcare. [143]

Cross-sectional analysis of CLHLS, 2018. Sample of 1617 disabled adults aged ≥60 with children or children-in-law as primary caregivers.

• Rural residence and lower socioeconomic status groups associated with under met care needs.

• Family caregiving is highly valued.

• COVID-19 affected family care model: no support measures introduced for isolated people in family care, poor access to medicines.

• Promote financial assistance to the oldest old, particularly in rural areas, to enhance access to services.

• Policies to support family caregivers: provide care skills training, respite services, psychological counselling, pilot an allowance.

Zhang, J., et al. (2022). Psychogeriatrics.

[144]

Cross-sectional survey of 1011 elderly residents ≥60 years old living at home with disabilities in Kunshan, Suzhou province, 2018.

• 80% chose living at home as their most preferred living arrangement.

• Individual income was a significant predictor of preferred living arrangement.

• Those with a monthly income of <3000RMB were less likely to choose living in a nursing home over at home.

• Older adults with <2 children were more likely to choose living in a nursing home or healthcare institution than at home as they were likely to have better financial support.

• Give special attention to older people with low individual income.

• Promote use of home-based services to suit preferences.

• Limitation: study excluded those with severe cognitive impairment.

Zhao, R., et al. (2021).

Journal of Health Care Organization, Provision and Financing. [145]

Cross-sectional study. Questionnaires with residents aged ≥65 in Chongqing.

• 85% choose home-based care: family care (56%) family and community care (29%).

• Preferences attributed to monthly income, number of children, insurance, health status, distance to children.

• Consider preferences for care, with reference to 90-7-3 policy guidelines

• Older adults are a heterogeneous group.

• Encourage doctors and nurses to work in institutions to provide integrated services.

Zheng X., et al. (2022).

Medicine and Society. [146]

Policy analysis of LTCI pilots.

• Restricted scope of coverage.

• Lack of unified assessment criteria.

• Funding mechanisms being explored by pilot cities.

• Attention should be paid to protecting people with different levels of disability and dementia.

• Content and types of services should be expanded e.g development of psychiatric support services.

Zhou, W., et al. (2021). Health Economics Research. [147]

Systematic review of LTC policies for older people in China.

• Poor resource integration due to multi-leadership and management fragmentation.

• Service system does not adequately meet LTC needs.

• Related departments to jointly set up a working group.

• Identify target populations for LTC and develop service capacity.