Study and Comparison of Elderly Care System in Germany and China Jingyan Li University of Bremen STUDY AND COMPARISON OF ELDERLY CARE SYSTEMIN GERMANYAND CHINA by Jingyan Li in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Health at University of Bremen. Supervisor: Prof. Dr. Stefan Görres Co-Supervisor: Prof. Dr. Henning Schmidt-Semisch Date of doctoral colloquium: 28.08.2019 ACKNOWLEDGMENT First of all, I am grateful to my supervisor, Prof. Dr. Stefan Görres, who has always trusted and supported me during the composition of this thesis. I would like to give my sincere gratitude for his patience, motivation, and immense knowledge. I have been extremely lucky and could not have imagined having a better advisor and mentor for my Ph.D study. My special thanks also direct to the co-supervisor of my thesis: Prof. Dr. Henning Schmidt-Semisch. Without his visionary guidance and steering, valuable comments and discussions, generous support and inspiration, this thesis would not be accomplished. I would like to give my gratitude to my colleague Christiane Degering-Machirus in IPP for her considerate assistance and help. Besides, my sincere thanks also goes to the col- leagues Nils Harenberg, Christin Ellermann, Rosa Mazzola and Fadua El Bouazzaoui for their insightful comments and encouragement. IPP is such a great institute where my sci- entific thinking and attitudes were fostered. Last but not least, I would like thank my family, my husband Lei for his continued sup- port and encouragement, my father Liang, my mother Shulan and my lovely daughters Leonie and Fenja. Without their unconditional supports, I would not be able to finish it. Jingyan Li April 2019 iii ABSTRACT In the context of globalization and information revolution, the interactions in terms of knowledge exchange between developed and developing countries in the world have be- came more and more intensified in many aspects. This thesis focuses on the analytic study and bilateral comparison of elderly care systems in Germany and China. As one of the most important social security components, elderly care has a huge impact on the social stability and sustainability. Thus, many countries have put it on a strategic position and strive for an ideal, efficient, sustainable and adaptive solution to confront the challenges brought by population aging. Germany, as one of the most developed countries in the world, has established a solid and comprehensive elderly care system based on its social welfare foundation. China, as one of the most rapid developing and populous countries, has undergone a radical demographic change and a rapid aging process in the last several decades, which pose massive challenges for contemporary China. Therefore, a compre- hensive study and comparison of the elderly care systems in both countries are of great scientific value for transferring theoretical and practical experiences. In the work, firstly a brief review and comparison of background information with respects to population de- velopment and living situation of the elderly in Germany and China are given. Then, the analysis of elderly care system is dissected in the following major dimensions: long-term care insurance (LTCI), forms of elderly care, and nursing education. Establishing a stable and sustainable long-term care insurance is imperative for elderly care system. The con- struction and development of LTCI in both countries are discussed and bilateral compared. The major forms of elderly care in the two countries, consisting of home care, community care, ambulant care and institutional care, are analyzed. Additionally, the insights of practi- cal and academic nursing education systems in the two countries are depicted as well, such as the present status and future reforms. In the end, the knowledge transfer and potential collaborations are addressed. v CONTENTS 1 Introduction1 2 Background 9 2.1 Population development.................................9 2.1.1 Population development in Germany.....................9 2.1.2 Population development in China....................... 15 2.1.3 Comparison of population development in Germany and China.... 23 2.2 Living situation of the elderly.............................. 25 2.2.1 Living situation of the German elderly.................... 26 2.2.2 Living situation of the Chinese elderly.................... 33 2.2.3 Comparison of living situation of the elderly in Germany and China.. 41 3 Long-term care insurance 53 3.1 Long-term care insurance in Germany........................ 53 3.1.1 Need of elderly care (Pflegebedürftigkeit).................. 55 3.1.2 Level of care services............................... 56 3.1.3 Important reforms of LTCI............................ 64 3.1.4 Financing of LTCI................................. 66 3.2 Long-term care insurance in China.......................... 70 3.2.1 Need of elderly care................................ 70 3.2.2 Development of LTCI............................... 74 4 Forms of elderly care 79 4.1 Forms of elderly care in Germany........................... 79 4.1.1 Care services.................................... 79 4.1.2 Nursing institutions............................... 83 vii CONTENTS 4.2 Forms of elderly care in China............................. 87 4.2.1 Home care..................................... 87 4.2.2 Institutional care................................. 89 4.2.3 Community care................................. 92 5 Nursing education 99 5.1 Nursing education in Germany............................. 99 5.1.1 Vocational training (Ausbildung)........................ 99 5.1.2 Reform of nursing education.......................... 102 5.1.3 Academic nursing education.......................... 104 5.2 Nursing education in China............................... 105 5.2.1 Elderly care education.............................. 105 5.2.2 Academic nursing education.......................... 109 6 Knowledge transfer: what could China learn from Germany 113 6.1 Construction of LTCI in China............................. 113 6.1.1 How to construct and implement social LTCI in China.......... 115 6.1.2 Social choice.................................... 116 6.1.3 Distribution object and distribution content................ 116 6.1.4 Service delivery.................................. 119 6.1.5 Financing of the social LTCI in China..................... 121 6.1.6 Risk control and regulation of social LTCI in China............. 121 6.2 Construction of nursing institutions in China.................... 123 6.2.1 Establish and improve the classification standards and evaluation mech- anism of nursing institutions.......................... 124 6.2.2 Normative construction, supervision and management.......... 125 6.2.3 Integrated elderly care and medical services................. 126 6.3 The development trend of nursing education in China............... 129 7 Knowledge transfer: what could Germany learn from China 137 7.1 Reform of academic nursing education in Germany................ 137 viii CONTENTS 7.2 Digital life of Chinese elderly people.......................... 139 7.2.1 Wechat: the most popular App throughout China............. 140 7.2.2 Usage of mobile payment among Chinese elderly people......... 143 7.2.3 Other common Apps for elderly people.................... 146 7.3 Traditional Chinese Medicine(TCM): an alternative for better elderly care... 148 7.3.1 TCM techniques.................................. 148 7.3.2 Concept of Yangsheng.............................. 154 8 Nursing Shortage and Collaborations 157 8.1 Nursing shortage in China................................ 157 8.1.1 Reasons of nursing staff shortage in China.................. 157 8.1.2 Countermeasures to resolve nursing shortage in China.......... 160 8.2 Nursing shortage in Germany.............................. 162 8.2.1 Causes and countermeasures of nursing shortage............. 163 8.3 Personal exchange program............................... 167 8.4 Joint education program................................. 169 8.5 German nursing curriculum export.......................... 170 9 Conclusion and Discussion 173 9.1 Population development and living situations.................... 175 9.2 Long-term care insurance................................ 176 9.3 Form of elderly care.................................... 176 9.4 Nursing education..................................... 177 10 Outlook 179 10.1 How to improve elderly care systems of China and Germany........... 179 10.1.1 Elevate social position of nursing professionals............... 179 10.1.2 Enhance education and training of nursing professionals......... 180 10.1.3 Resolve staff shortage of elderly care professionals............. 181 10.2 What can be learned between China and Germany................. 182 10.2.1 Establish statutory LTCI system in China................... 182 ix CONTENTS 10.2.2 Reinforce national support and regulation for elderly care system in China........................................ 183 10.2.3 Develop community care in Germany.................... 185 10.2.4 Improve elderly life qualities with advanced technologies in Germany. 185 10.2.5 Promote TCM in Germany........................... 186 List of Abbreviations 189 Appendix 199 Bibliography 199 List of Figures 229 List of Tables 233 x 1 INTRODUCTION Under the background of globalization and information revolution, the interchange in terms of economy, culture, technology, arts and social systems between different countries has become much more important and valuable. As