China's National Health Commission Reports Reversal of Doctor-Nurse Ratio Imbalance in 2017 and Outlines Four Key Challenges in Elderly Care

At 10:00 a.m. on May 10, 2018, the National Health Commission held its regular May press conference. The meeting was moderated by Mr. Liu Zhefeng, Director of the News Division of the Department of Publicity of the National Health Commission. Ms. Jiao Yahui, Deputy Director of the Bureau of Medical Administration and Hospital Management; Mr. Wen Daxiang, Deputy Director of the Shanghai Municipal Health and Family Planning Commission; and Ms. Wu Xinjuan, Director of the Nursing Department at Peking Union Medical College Hospital, President of the Chinese Nursing Association, and recipient of the 43rd Florence Nightingale Medal, attended the press conference and delivered remarks.

The press conference focused on introducing the development of China’s nursing industry. Attendees presented overviews of the national nursing landscape, the development of nursing services in Shanghai, and the growth of elderly care services, while Peking Union Medical College Hospital shared its achievements in deepening high-quality nursing care.

VCBeat (WeChat ID: vcbeat) has selected excerpts from the press conference transcript to monitor the latest developments in China’s nursing sector.

Strengthening the nursing workforce and promoting the reform and development of the nursing profession and industry are important components of implementing the Healthy China Strategy, as well as an objective requirement for establishing a health service system that covers the entire population and all life stages.

The State Council promulgated the Regulations on Nurses in January 2008, which came into effect on May 12 of the same year, International Nurses’ Day. These regulations safeguard the legitimate rights and interests of nurses from a legal perspective, clarify their rights, obligations, and practice standards, promote the healthy development of the nursing profession, and ensure medical safety as well as the health of the general public.

This year marks the 10th anniversary of the implementation of the Regulations on Nurses. Over the past decade, under the strong leadership of the CPC Central Committee and the State Council, governments at all levels, health administrative departments, and medical and health institutions have fully implemented the Regulations on Nurses, adopting effective measures to stabilize and develop the nursing workforce. The vast majority of nursing professionals have conscientiously fulfilled their responsibilities and obligations, actively promoted high-quality nursing services, and made significant contributions to improving the health status of the entire population. Since the implementation of the Regulations on Nurses, the nursing profession has achieved rapid development and remarkable results, primarily reflected in the following aspects.

By the end of 2017, the total number of registered nurses in China exceeded 3.8 million, accounting for 42.3% of professional and technical personnel in the health and family planning sector. Two significant milestones stand out: the promulgation and implementation of the first “11th Five-Year” Nursing Development Plan Outline in 2005, and the enactment of the Regulations on Nurses in 2008.

In 2005, the number of nurses was 1.35 million; by 2008, it had reached 1.678 million. In 2017, the number of registered nurses exceeded 3.8 million, representing a 181.6% increase compared to 2005 and a 126.5% increase compared to 2008.

The number of nurses per 1,000 population increased from 1.03 in 2005 to 1.25 in 2008, and further rose to 2.74 by 2017.

The national nurse-to-physician ratio improved from 1:0.66 in 2005 to 1:0.79 in 2008, reaching 1:1.1 by 2017, thereby reversing the previous imbalance where nurses were outnumbered by physicians.

In 2017, the nurse-to-physician ratio reached 1:1.54 in tertiary hospitals and 1:1.46 in secondary hospitals. Nearly 800,000 nurses were engaged in nursing work at the primary care level.

Nurses with an associate degree or higher account for 67% of the total nursing workforce. The level of specialized nursing care continues to improve, playing a significant role in both daily nursing practice and medical response during major emergencies.

The nursing service philosophy has shifted from being “disease-centered” to “patient-centered,” and the service model has evolved from merely assisting physicians in completing treatment tasks to focusing on patients’ physical and mental health needs. The professional technical standards of nursing continue to improve, making nursing practice more closely aligned with patients, clinical care, and society.

In 2017, high-quality nursing services achieved full coverage in tertiary hospitals, and nearly 90% of secondary hospitals also implemented such services, significantly enhancing patients’ sense of gain in accessing medical care. According to third-party evaluations of improvements in medical services, public satisfaction with nursing care was the highest.

Nursing care serves individuals throughout the entire continuum of life, from birth to death, playing a vital role in acute-phase diagnosis and treatment, chronic-phase rehabilitation, and end-of-life care and support.

Across China, many regions and healthcare institutions are proactively adapting to shifts in the disease spectrum and the aging population. They are continuously enriching the scope of nursing practice by extending services into communities and homes, providing elderly care, chronic disease management, rehabilitation nursing, long-term care, and hospice care. These efforts have further met the public’s diverse and multi-level health service needs.

Currently, nursing care still faces issues of unbalanced and inadequate development when compared with the diverse and multi-tiered health needs of the public.

Shanghai is one of the first cities in China to enter an aging society, characterized by a remarkably rapid pace and high degree of population aging. By the end of 2017, individuals aged 60 and above accounted for 33.2% of Shanghai’s registered population, while those aged 80 and above constituted 5.5% of the total.

To meet the growing demand for elderly care services in urban areas, Shanghai has continuously strengthened the management of medical and nursing care for the elderly. Adhering to the principles of balancing government leadership with market-driven mechanisms and optimizing the regional allocation of health resources, the city has achieved significant improvements in the capacity and quality of its elderly medical and nursing care services.

Since the 12th Five-Year Plan, Shanghai has continuously implemented policies to increase the number of geriatric medical and nursing beds in the city. By combining the optimization of existing resources with moderate expansion of new capacity, the number of geriatric nursing beds has been gradually increased.

On one hand, treatment beds in existing public secondary medical institutions and community health service centers are being gradually converted into nursing care beds. In 2013, Shanghai issued the Implementation Opinions on Establishing Geriatric Nursing Beds in District and County General Hospitals, requiring each district’s general hospital to establish no fewer than an average of 50 geriatric nursing beds. For district general hospitals that set up such beds, a one-time subsidy of RMB 10,000 per bed was provided through the Shanghai Welfare Lottery Public Welfare Fund.

On the other hand, efforts have been made to encourage and support the establishment of elderly care institutions and promote the diversified development of nursing stations. In 2016, Shanghai issued the "Shanghai Nursing Station Management Specifications" and the "Notice on Encouraging Social Forces to Develop Nursing Stations," aiming to extend medical and nursing services into communities and households, thereby meeting the growing public demand for basic medical and nursing care. In 2017, Shanghai formulated the "13th Five-Year Plan for the Development of Shanghai’s Elderly Medical and Nursing Care Service System," which further clarified requirements to increase the supply of elderly nursing care resources in the city and improve the quality of elderly medical and nursing services.

As of the end of 2017, the city had a total of 26,599 beds for elderly medical and nursing care. The number of nursing hospitals in the city reached 46, including 9 government-run and 37 privately operated facilities, with a total of 7,913 beds. The number of nursing stations in the city reached 108, including 9 government-run and 99 privately operated ones. The number of elderly medical and nursing care beds established by social capital in the city reached 6,051, accounting for 22.7% of the total.

In 2013, Shanghai initiated pilot programs for a medical and nursing care security plan targeting the elderly. Starting in January 2017, as one of the first 15 cities nationwide to pilot long-term care insurance, Shanghai implemented the system on a trial basis in Xuhui, Putuo, and Jinshan Districts, achieving phased results.

In accordance with the arrangements made by the Shanghai Municipal Committee of the Communist Party of China and the Shanghai Municipal People’s Government, a pilot program for long-term care insurance was launched citywide on January 1, 2018. The program provides services or financial support for basic daily care and medically necessary nursing care closely related to daily living activities to individuals with long-term disabilities who have been assessed as meeting specified levels of care needs. This initiative not only delivers urgently needed long-term care services to elderly persons with long-term disabilities but also effectively alleviates their economic burden.

In accordance with the citywide unified division of responsibilities, Shanghai’s health and family planning authorities took the lead in advancing the development of assessment standards, collaborated with human resources and social security as well as civil affairs departments to manage assessment agencies, train assessors, and ensure assessment quality control. Efforts were also made to strengthen the establishment of service institutions such as privately operated nursing stations, bolster the workforce of assessors and nursing staff, and coordinate with relevant departments to formulate supporting policies. By the end of 2017, more than 80,000 assessments had been conducted across Shanghai based on these assessment standards.

Shanghai is continuously advancing the development of its family doctor system, actively exploring the implementation of “1+1+1” contracted partnerships with medical institutions, and prioritizing elderly populations as key targets for these contracted services.

As of April 23, 2018, the number of permanent residents in the city who had signed up for the “1+1+1” contract-based family doctor service reached 3.92 million, including 2.77 million elderly people aged 60 and above, with a signing rate exceeding 60% among this age group.

Among enrolled residents, 73% of outpatient visits occurred within the “1+1+1” healthcare institution consortium. Of these, 52% of contracted outpatient visits took place at the community health service center with which they were enrolled.

To further advance the integration of medical and elderly care services, Shanghai has established community health service centers as a key platform for delivering health services to the elderly. Currently, services provided to older adults account for approximately 60% of the total workload at these centers. Across the city, community health service centers have achieved full coverage in signing service agreements with both elderly care institutions and custodial care facilities.

During the Q&A session, Jiao Yahui stated that population aging is a major challenge facing the country. According to statistics from the National Bureau of Statistics, China currently has approximately 240 million people aged 60 and above, and 160 million people aged 65 and above, among whom some are disabled or partially disabled.

The National Health Commission will start by addressing the most urgent medical and care needs of the elderly and is currently studying relevant policies. In the next step, the Commission will, on one hand, continue to consolidate the achievements made in nursing, implement the “13th Five-Year” Nursing Plan, further strengthen the development of the nursing workforce, expand high-quality nursing services, and gradually meet patients’ health needs.

Although the number of nurses in China has currently reached 3.8 million, there is still a significant gap between supply and demand relative to needs. The contradiction between unbalanced and inadequate development and societal demands is particularly pronounced in the field of nursing.

Therefore, the next step is to improve elderly nursing and care, with a focus on addressing several key issues. The first is to determine who will provide the care. Nursing services should be extended from hospitals to communities and into homes. On one hand, we must significantly expand the number of nurses; on the other hand, we need to strengthen the workforce of certified nursing assistants specializing in elder care. Thus, to develop medical care for the elderly, the primary issue to resolve is identifying the caregivers.

Second, we must address the question of who requires care. China currently has 240 million elderly individuals aged 60 and above. This population includes healthy seniors, those with chronic diseases, and those who are disabled or partially disabled. The National Health Commission is developing standards for elderly care assessment, which will determine whether these seniors require institutional care, community-based care, or home-based care.

Through these different approaches, payment channels also vary. Within medical institutions, costs may be covered by medical insurance, while in certain institutions or community settings, long-term care insurance may serve as the payer. Additionally, commercial insurance models are being developed to help cover some of the costs associated with home-based care. This addresses the question of who pays for caregiving services.

Third, we must address the issue of care provision. We should encourage elderly care institutions to establish medical facilities to facilitate the integration of medical care and elderly care.

Primary healthcare institutions and community health service centers provide community-based and home-based care for the elderly through contract signing, the establishment of home hospital beds, and home visit services.

Some elderly individuals require a team of professionally trained caregivers to provide in-home care services.

From the perspective of our national conditions, institutional care is not our primary direction. In the future, the main providers and models of care for our elderly population should be community- and home-based. Particularly within communities, many regions are currently exploring mutual-aid elderly care models. In urban areas, there are concentrated senior apartments and community facilities; in rural areas, there are “Happiness Homes” for the elderly promoted by civil affairs departments, as well as mutual-aid care models. Daily health services are provided by village doctors near village clinics, addressing the question of where care should be delivered.

Fourth, we must address the issue of who will pay for caregiving, namely, financing. With regard to long-term medical care, we can draw on the experiences of other countries; Japan, for instance, has done an excellent job. In addition to health insurance, Japan has a long-term care insurance system designed to address the long-term medical and care needs of its elderly population.

In China, the human resources and social security departments are leading pilot programs for long-term care insurance in selected cities across the country, aiming to alleviate the financial burden of long-term medical care costs to some extent, with varying models adopted by different regions.

Furthermore, China should vigorously develop commercial insurance. Commercial insurance companies can design long-term care and nursing insurance products tailored to the elderly, thereby playing a supplementary role.