In May 2021, results of the much-awaited Seventh National Census were publicized: China’s total population in 2020 was 1,411.78 million, with an increase of 5.38% compared with 2010 (i.e. the result of the Sixth National Census in 2010) and an average annual growth rate of 0.53%. In 2020, people aged 60 and above around the country hit 264.02 million, accounting for 18.70% of the total number. Among them, those aged 65 and above reached 190.64 million, accounting for 13.50% of the country’s total. Compared with 2010, the proportion of the population aged 60 and above increased by 5.44%. When it comes to geographical terms, there are 16 provinces with more than 5 million people aged 65 and above, of which 6 provinces have even more than 10 million elderly people. When put in a worldwide comparison, what’s happening in China is close to deep aging, because, according to the UN standard, when a country’s population aged 65 and above is more than 7%, it will be labelled as an aging society; and when the number doubles to 14%, it will be labelled as a deep aging society. Obviously, the process of aging China is accelerating.

In order to effectively respond to the aging in China, the CPC Central Committee and the State Council issued the Opinions on Strengthening the Work on the Elderly in the New Era (hereinafter referred to as the Opinions) in November 2021. It is pointed out in the document that the positive view on aging and the concept of healthy aging shall be integrated into the whole process of economic and social development. More efforts should be made on accelerating the establishment and improvement of relevant policy-making systems and institutional frameworks, so as to promote the high-quality development of aging-related affairs and embark on a reasonable track with Chinese characteristics to actively respond to this challenge. Immediately afterwards, the 14th Five-Year Plan for the Development of National Aging Causes and Elderly Care Service System (State Council [2021] No. 35) and the 14th Five-Year Plan for Healthy Aging jointly formulated by multiple ministries and commissions were promulgated on December 30, 2021 and March 1, 2022, respectively, and China’s efforts to cope with aging has entered a new stage of development.

So, what are the exact meaning of the positive view on aging and the concept of healthy aging, and how are they reflected in policies recently publicized? Besides, what needs further attention from policy-makers? This article will sort them out and discuss these issues in detail.

1. Positive Outlook on Aging: Theories and Practices

(1) Core Connotations

Against the backdrop of great changes not seen in a century, uncertainties can be seen in various sectors such as global climate change, technological innovation and international relations. How these factors evolve will bring different impact on different countries in both near and long terms. However, it is quite certain that aging has become a common challenge for all high-income countries and most middle-income ones. Therefore, how people reflect on and react to this hugely influential phenomenon is of great importance for individuals, families, enterprises, organizations, institutions, societies and countries. What we need is not passive reactions but active actions, so as to seize the opportunities and respond to the challenges.

According to the negative view on aging, based on a narrow biological view as well as from a traditional perspective of labor-intensive agricultural or industrial civilizations, aging will admittedly bring about all kinds of problems and challenges, such as the decreasing labor force, the higher cost for medical service, the increasing spending on elderly care as well as the negative impact on the macroeconomic development by factors mentioned above. A negative view on aging is against with longevity and health, i.e. the common and eternal pursuit of mankind. It also goes against the philosophy of putting people’s lives as the priority which is part of the core values of socialism with Chinese characteristics in the new era. Such a wrong mentality would encroach our tradition of respecting the old through filial deference and kill the opportunity for finding new engines for economic growth. Moreover, it might also exacerbate inter-generational conflicts and do harm to the stability and harmony of our society.

In sharp contrast to negative views on aging, a positive view on aging is a brand-new paradigm and philosophy based on historical materialism and dialectical analysis. It mainly includes three parts: a positive view on the phenomenon of aging, an active response to the challenges of aging, and an upbeat attitude to explore more values in an aged society.

The positive view on aging is a scientific concept. The direct causes of aging are the increase of average life expectancy and the decline of birth rates, which are both undeniable trends that will inevitably appear when a country’s economic and social development reaches a certain stage (poor countries have no aging phenomenon). While longevity is one of the ultimate pursuits by human, aging is, to some extent, a sign of economic development and social progress. Therefore, we’d better welcome the arrival of an aging society with gratitude and pride. For the disabled elders who have made diligent contributions to the creation of social wealth and to the material foundation for the arrival of such an aging society, we should provide necessary and sincere elderly care to express our respect and appreciation. At the same time, how we treat our forefathers will determine the way in which our sons and daughters treat us. In addition, the expansion of the consumption of elderly-care products and services (i.e. the development of the silver-haired economy) might be conducive to stimulating China’s macroeconomic growth and to promoting technological progress.

Since it is a scientific concept, the positive view on aging would not shy away from the various challenges that inevitably arise but also focus on how to deal with these challenges in a more active and effective way (rather than passively reacting to the emerging challenges). That is to say, the positive view on aging is an active way of thinking that tries to solve problems at their early stages, minimizing health risks as well as preventing diseases and disability. On the one hand, we can take the initiative to learn from valuable experience and lessons gained by countries that entered the aging society earlier; on the other hand, we can also actively explore our own comparative advantages in terms of both social system and national culture. Just like we gave full play to the advantages of a nationally-coordinated mechanism that produced great achievements in the fight against COVID-19, we should also hold the four self-confidences in actively responding to an aging population.

One of the most unique perspectives offered by a positive view on aging is that senior citizens can still have a huge stage for continued performance. It stresses multifaceted contribution by the old to the society, rather than regarding them as a burden, including the inheritance of cultural assets and the maintenance of social stability. It should be noted that concepts like labor force, support coefficient and retirement age are all production of human definition, which is subject to changes according to new realities of each historical period. Generally speaking, the elderly group can be roughly divided into the sick and disabled as well as the active and vigorous. The latter can not only continue to live and learn, but also work. As long as rules permit and the market demands, these active elders can, as producers, not only engage in manual work in traditional agricultural and industrial sectors for a few more years (for example: in 2016, there were 314.22 million people working for agricultural production and management, with almost 33.6% of them aged 55 or above and only 19.2% of them aged 35 or below). Besides, in a knowledge-driven economy, seniors are indispensable teachers, mentors and guides for the younger generation. Among those aged 60 and above, 55.83% are aged 60-69 while there are 36.69 million people with high school education, which means that this group of people have rich knowledge, experience and skills that are very useful for the society. Since this group of seniors are generally healthy, they have great potential for continued contribution.

According to our observation on Japan, Singapore and other countries, various kinds of policies can be established to encourage the elderly to continue their careers, especially in some service industries where elderly or even super-elderly workers can be ubiquitously seen. The inspiration from the Maslow’s Theory on the Hierarchy of Needs is that actively encouraging the elderly to give full play to their remaining potential for even higher fulfillment by their skills is a good way to turn them from burdens for the young into contributors to the society. In this case, there would be a longer period of time for a man to serve the society, therefore enhancing the sense of achievement and fulfillment. In practice, the loss of sense of value and self-worth really is one of the reasons for developing physical or mental illness around one’s retirement (i.e. the peri-retirement period).

(2) A Positive View on Aging: Policies and Strategies

In the text below, let’s adopt a positive view on aging and summarize the main content of the 14th Five-Year Plan for the Development of National Aging Causes and Elderly Care Service System (State Council [2021] No. 35)

First, the overall content of this document fully reflects a positive view on aging. In terms of the guiding ideology, the document adopts Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, and proposes the coordinated development of the cause of serving the elderly and aging-related industries. It is clearly stated that efforts should be put both in caring for the elderly and contribution by the elderly. In terms of fundamental principles, the document advocates the cooperation and collaboration for shared outcomes, that is, the joint participation and common responsibility by the government, the society, families and individuals. This aims to, on the one hand, create an elderly-friendly society where senior citizens can enjoy their life and, on the other hand, encourage the old to establish a healthy view on aging and a positive attitude towards lifelong development so as to continue their contribution to the economic and social development of the society. When it comes to target-setting, the document not only emphasizes a service system made in a systematic and continuous way, but also pays attention to the active empowerment by the government for the guarantee of support and the environment of policy-making.

Second, a positive view on aging would guide the establishment and improvement of a mature social security system. This includes: improving the current pension fund mechanism and elderly-related medical system; establishing an insurance system for long-term elderly-care; and optimizing social assistance and social welfare systems for the elderly. The author believes that the most urgent tasks at this moment are: the dual assessment on the physical disability and economic difficulty about the recipients of elderly care; the dual guarantee of support from both central and local governments; and establishing a social security system for long-term elderly care system. All of these suggestions aim to allocate limited public resources to those most in need.

Third, China should establish a better service system of elderly care under the guidance of a positive view on aging. On the one hand, elderly-care services should be extensive, requiring all localities to issue a full list of basic elderly-care services according to their fiscal capacity. After analyzing a senior citizen’s health, mobility and financial status, the society would then provide corresponding social security allowance, daily care, rehabilitation after recovery, additional assistance and other necessary categories of service. The document also requires that such a list should clarify the recipient, content, standards and expenditure responsibilities of each service, and make timely adjustments according to the progress of economic, social and technological development. Besides, it is also suggested that new forms of services for the elderly be established and the development of Internet+ elderly care services be promoted. On the other hand, the document stipulates that there should be various forms of organization for elderly care services. Publicly-run elderly care institutions must shoulder the responsibility for providing basic guarantees, particularly in rural areas, while privately-run agencies should be supported to build professional and large-scale elderly care institutions that can bring medical treatment and caring services together. By doing so, these institutions would take the lead and serve as good examples for the improvement of long-term care service standards, professional training for talent pools, information-based intelligent management as well as the promotion and application of rehabilitation tools.

Fourth, it is vital to vigorously develop the silver-haired economy under the guidance of a positive view on aging. Industries making elderly-related products will be fostered and expanded by strengthening the research & development and manufacturing of elderly products, promoting the application and promotion of high-quality products as well as encouraging the development of industrial clusters. At the same time, elderly-related products would involve more technological support and smart designs by means of the research-industry transformation of elder-related technologies, the development of health-promoting supportive tools and the publicity of smart products for the elderly. In the meantime, the orderly development of inclusive financial services for the elderly can further increase their purchasing power for both the products and services they need, which is also a strong macro-economic boost for China.

Fifth, under the guidance of a positive view on aging, an elder-friendly environment shall be established. Family members, in the first place, should shoulder the responsibility of taking care of their seniors, while additional support will also be given for household elderly care, so as to fully implement the good tradition by the Chinese nation regarding the respect for the elderly and the deference to the seniors. After that, communities should make a full transformation to create an elderly-friendly environment, particularly the promotion of accessible public places. Moreover, further improvement should be made in terms of medical services, social insurance, civil affairs, financial services, telecommunication, postal services, cross-border businesses, facility bill payment and all other frequently-used services, so that they can better serve the need by the elderly, particularly regarding smart services and electronic devices (i.e. typical difficulties in the digital divide). Last but not least, mechanisms should also be improved to ensure the legitimate rights and lawful interests of the elderly. This shall be achieved by concerted efforts from multiple parties, including volunteers, so that the whole society is surrounded by the good tradition of respecting, loving and helping the elderly.

Sixth, under the guidance of the positive view on aging, we should support the social participation by the elderly. Universities for senior citizens, run by different governmental departments, enterprises in various industries and higher educational institutions, would receive more encouragement for further development. This aims to encourage seniors to continue their roles in the society by, for example, establishing a particular database of senior human resources to provide job opportunities, occupational training and assistance for innovation and entrepreneurship for seniors who really want to work. Laws, regulations and policies must be in place to protect the rights for employment and entrepreneurship by the elderly, with more support for their engagement in business and production in accordance with laws and regulations, together with social welfare undertakings. Besides, retirement could be somehow postponed for professional and technical personnel based on the actual needs by employers and the true willingness by the elderly. By expanding the supply of cultural services for the elderly, we shall further encourage their participation in sports and fitness exercises, and promote the integrated development of health care and tourism, so as to enrich the cultural, physical and leisure life of the elderly, thereby significantly improving their sense of gain, happiness and security.

2. Healthy Aging: Theories and Practices

(1) Core Connotations

Aging is an exclusive process for human being with changes in both natural and social terms. At the individual level, this process is part of a full life cycle from birth, childhood, adolescence, and adulthood, to aging and death; at the collective level, aging is also part of the full life cycle of a particular group of people thanks to human heredity and reproduction. So far, human beings have not yet invented any means for immortality, so death is inevitable. However, when it comes to how to prolong our life expectancy and improve the quality of our lives, human beings have more and more methods with economic, societal, scientific and technological development.

It is true that as people get older, they are more probable of suffering from various diseases and the demand for medical resources will undeniably increase. This is a natural law. Therefore, aging with sickness and disability is a reasonable concept with the core idea of providing medical care for the elderly. However, healthy aging is comparatively a broader philosophy that not only emphasizes the restoration of health and the treatment for diseases, but also pays more attention to the prevention and control of diseases as well as the promotion of personal health, with the highest goal for a peaceful end-of-life free from illness. According to the definition by the World Health Organization (WTO), being healthy means the absence of illness and a comprehensively sound status in physical, mental and social terms. Therefore, healthy aging means trying to make the elderly less sick, if not free from illness, and trying to maintain their physical and mental health. At the National Health Conference held in August 2018, General Secretary Xi Jinping proposed that we must advocate a healthy and civilized way of life, putting health in a broader spectrum and changing our focus from the treatment of diseases to the promotion of people’s health; we also need to establish and improve an educational system to raise people’s awareness for health, and promote further integration of public sports and people’s well-being. Therefore, the author intends to summarize these ideas into the term positive health, and has made such a proposal for positive health when attending an international conference, particularly by calling all governmental agencies to integrate people’s health into their policy-making; calling medical personnel to pursue professional directions that are in line with people’s core interests of having a good health; and calling all individuals to have a stronger awareness for health so that they shoulder a major share of the responsibility of their own health and help with the health of others.

(2) Healthy Aging: Policies and Strategies

In the text below, we will sort out the main content of the 14th Five-Year Plan for Healthy Aging (hereinafter referred to as the Plan) from the perspective of healthy aging in the true sense instead of focusing on traditional medical services.

Key Objectives and Fundamental Principles: The key objectives of the Plan is that, by 2025, the health security system for the elderly be more complete, the social environment for the healthy life of the elderly be more friendly, the health needs of the elderly be better met, the health level of the elderly be further improved and the life expectancy be even higher. Approaches to effectively achieve these key objectives shall be based on, as the Plan stipulates, four basic principles:

First, put health first and provide a full range of services. We shall take the health of the elderly at the center of our work and provide the elderly with services including health education, preventive health care, disease diagnosis and treatment, rehabilitation nursing, long-term care, palliative care, etc. Second, advocate demand-oriented and high-quality development. Guided by the health needs of the elderly, we need to continue the supply-side reform, promote the high-quality development of health services for the elderly, and boost the deep integration of general medical care and elderly care services. Third, let the government to take the lead and the public to participate in this undertaking. We need to give full play to the leading role of the government in promoting healthy aging, encourage the contribution of private capital, and build a multi-level and diversified health service system for senior citizens. Family members should first shoulder their due responsibility for elderly-care, and then together build an aging-friendly society. Fourth, ensure fairness and accessibility with collaboration and sharing. We need to protect the rights and interests of all the elderly as the starting point, and then continuously deepen the reform of the system and mechanism by actively promoting the balanced rural-urban and inter-regional development of health services for the elderly. By doing so, it will be guaranteed that health services are equally accessible for and commonly shared by all. Further, the Plan proposes the following tasks to implement these four basic principles:

First, strengthen the awareness of health among the elderly so that they, in the first place, care about their own health. Such an educational campaign shall include specific measures: expanding the content of health education for the elderly, forming a diversified supply of health education services targeting at seniors, and innovating such provision through both traditional media and new media like vlogs, WeChat official accounts, Weibo and smartphone apps.

Second, establish a better health-care system, on both physical and mental terms, that focuses on the prevention of diseases instead of the passive response to them. Specific measures include: improving basic public medical services to improve the general health of the elderly, providing psychological care services for the elderly, and promoting the integration of sports and health (for example, identifying suitable sports programs for the elderly with appropriate intensity, publishing guidelines for physical fitness activities for the elderly, and incorporating physical exercises into the prevention and rehabilitation of chronic diseases among our senior citizens).

Third, provide better rehabilitation and nursing services. We should give full play to the role of rehabilitation and medical services in the overall health industry for the seniors, so as to provide elderly patients with prompt, systematic, professional and continuous rehabilitation medical services that are essential for their recovery. Meanwhile, it is also important to build the coordination by physicians and therapists with supportive equipment. Further, it is essential to establish a comprehensive nursing service system covering the acute phase, chronic phase, rehabilitation phase, long-term care phase, and end-of-life phase for elderly as well as an extensive network of elderly-care services that are supported by social institutions, helped by community agencies and, of course, based on individual households. Last but not least, palliative care services should also be improved with pilot programs and multidisciplinary support so that patients suffer less at the end of their lives.

Fourth, promote the development of the scientific and technological industries for healthy aging. Specific measures include: strengthening the scientific research on the health of the elderly, promoting the sustainable development of the health-care industry for the old, and making full use of information technology means, such as the Internet, Internet of Things (IoT) and big data, to improve the quality and efficiency of intelligent health services for our senior citizens.

In conclusion, a positive view on aging and healthy aging complement each other. A clear understanding and firm establishment of such a positive view on aging will help the whole society to correctly understand this trend for human society, so as to actively and effectively respond to the challenges of aging and, further, turn challenges into opportunities that can promote sustainable economic and social development. Healthy aging is an essential part of the positive view on aging, and it is the prerequisite to put such view into practice and the foundation for keeping an aging society dynamic. Guided by the fundamental principles of Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, we’d keep pace with the times and act in accordance with the changing realities, so as to faithfully implement the policy of integrating the concept of a positive view on aging and the idea of healthy aging into the entire process of economic and social development proposed by the CPC Central Committee and the State Council. We will, by all means, find our own way with Chinese characteristics to address aging in a positive manner.

Special appreciation goes to Zhang Yuou, Liu Yang and all those who have provided their help for the research involved in this article.

Author: Prof. Liu Yuanli, Counsellor of the State Council, Executive Dean, Professor and PhD Supervisor at the School of Health Policy and Management of Peking Union Medical College