Long-term care system for people with dementia in China: A critical analysis

Long-term care system for people with dementia in China: A critical analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long-term care system for people with dementia in China: A critical analysis Haiyan Chong, Li Liu, Xiuying Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4263935/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Chinese people with dementia account for approximately a quarter of the global burden of diseases, while the traditional long-term care system that heavily relies on families is eroding. In response, the Chinese Government has launched several policies for dementia.We aim to describe governance structure for long-term care, synthesizing the policy developments since 2010, and analyze current issues and challenges in the system, and provide policy recommendations. Method A critical analysis was conducted by looking for government reports, news, and searching the PubMed, Web of Sciences and CNKI database on China’s long-term care system for dementia from 1 January 2010 to 30 August 2023. Results We described Chinese long-term care system for people with dementia from three overarching aspects: governance and policy, service delivery, and the system of financing. We found that the system is characterized by no specificity and continuity in policy, as well as lacking sections of professional long-term care services. Moreover, inconsistent designs in financing sources and eligibility have also been fully concerned. Conclusions This study demonstrated the vitality of the dementia service market has yet to be fully stimulated in the Chinese mainland, problems such as unbalanced and inadequate development, insufficient effective supply, and low service quality still exist, and the long-term care services needs for people with dementia have yet to be effectively met. Currently, China’s policy for people with dementia is developing. Lessons from international experiences are may able to help China conduct novel health policy. It’s urgent to establish a unified national services system to promote the healthy development of care services for people with dementia. Dementia Long-term care China Policy system Critical analysis Figures Figure 1 Figure 2 Background Population aging is a global challenge. In China, 209.78 million adults were 65 years or older in 2022, representing 14.90% of the country’s population (1). As the leading cause of disability for the older population (2), dementia involving the disruption of functional networks underlying cognition, personality, behavior, and sensorimotor, eventually attacking an individual’s autonomy (3). Dementia increases with age (4), which is the fourth leading cause of death amongst adults over 65 years in China (5). With the prevalence rising from 5.14 % in 2014 (6) to 5.60 % in 2019 amongst people 65 years or older (7), Chinese people with dementia account for approximately a quarter of the global burden of diseases (8). The rapid increase of people with dementia led to enormous social and economic consequences (9). In China, dementia costed 1.47% of the country’s gross domestic product (GDP) in 2015, larger than the global average of 1.09% (10). Dementia adversely affects health and well-being. People with dementia are more likely to suffer cognitive impairment, hallucinations, delusions, and severely impaired social functioning (3). There is currently no cure for dementia, with the life expectancy for people with dementia lasting 8 to 10 years as a consequence (8). Additionally, more than 1,370 people aged 60 or older lose their bearings and go missing every day, according to the China White Paper on the Lost Elderly, dementia and lack of care services were cited as the leading factors in the disappearances (11). Thus, the need for LTC is common for People with dementia. Traditionally, the Chinese provide LTC to older people within families. However, China’s rapid demographic shifts were exacerbated by the one-child policy, and have made such duties increasingly difficult to fulfill. Growing burdens are borne on the public healthcare system, resulting in important implications for the LTC system (12). Analyzing current policy system, challenges, and offering recommendations of China's LTC for People with dementia can help the government for practicing and policy decisions, thereby improving People with dementia’ well-being in the future. In this paper, we focus on the care for people with dementia in the Chinese mainland, we use long-term care (LTC) to describe the scope of formal care and services in support of people with dementia. We describe China’s policy system for dementia and analyze issues and challenges in building its LTC service system for people with dementia based on government reports, news, literature reviews, and studies during 2010-2023. Lessons from the international long-term care experiences for dementia, we offer policy recommendations to improve and strengthen the long-term care system for people with dementia in China. Method We will make a systematic and comprehensive critical analysis of the policy system based on lots of government reports, news, and literature of the LTC system for people with dementia in China. We searched the PubMed, Web of Sciences, and CNKI database to identify original and review articles in English and Chinese language. Moreover, we surf previous government reports and news looking for information on China’s LTC system for dementia, to we deliver the detailed description for performing a critical analysis. The keywords used were long-term care, dementia, China. Relevant articles, government reports and news published between 2010 and August 2023 were critically reviewed, analyzed, and summarized. Results China’s LTC system for dementia Similar to other countries, LTC services in China are supplemented by formal (paid) care, such as welfare homes, nursing homes, community-based day-care centers, household assistants, community hospitals, and so on. We described China’s LTC system for dementia from three overarching aspects: governance and policy, service delivery, and the system of financing (Figure 1). 1. Governance and policy 1.1 Governance structure In China, the National Bureau of Statistics is responsible for national economic, workforce employment, social development, and service industry statistics, and the census (13). The Ministry of Health, namely, the National Health Commission, takes charge of information on health system resources, public health services, drug management, food safety, and population health surveillance et.al (14). The National Healthcare Security Administration is responsible for information that are related to social health insurance, medical assistance, and drug tendering (15). The Ministry of Civil Affairs is responsible for the formulation and implementation of the pension service system, and the welfare and assistance of the older adults (16). The National Medical Products Administration is responsible for information on the approval, and manufactural records of drugs and medical equipment (17). 1.2 Policy development In recent years, efforts have been made by the Chinese government to increase benefits for older adults. Thus, relevant supporting policies also have been issued to improve the supply of LTC services for people with dementia(Table 1). However, most policies for dementia in China still are just mentioned with a simple proposal or overview; even people with dementia are only included under the category of disabled older adults. Currently, no specific and overall planning and implementation were implied, leading to dementia and its associated problems have been not directly addressed in China’s policy. The policy system in China for dementia still faces the challenge of population aging and inefficient delivery on the side of the supply, growing burdens are borne on both health expenditures and individual disease. Table 1 Policy development in LTC for dementia in China 2010-2023 Policy dimensions Year Policy body Document title Main content Policy object Service system 2011 The General Office of the State Council National plan for the development of pension services and system (2011-2015) Establish the three-tier LTC system to facilitate LTC Older adults 2015 The General Office of the State Council National Mental Health Work Plan (2015-2020) Focus on common mental disorders (including dementia), and improve preventive and treatable mode People with mental disorders 2015 The General Office of the State Council Guidance to promote the combination of medical care and LTC services Establish and improve the mechanism to combine medical institutions with nursing home Older adults 2017 The General Office of the State Council The 13th Five-Year Healthy Ageing Plan (2016-2020) Popularizing health and care services for individuals. Planning to strengthen the dementia prevention and service supply system. Older adults 2019 The General Office of the State Council Document to promote the development of pension services Establish and improve the policy framework for pension on managing, funding, workforce and the quality of services. Stressing government-owned and public nursing home provide free or less charge care services for low in-come people with dementia. Older adults 2021 The General Office of the State Council Document to strengthen ageing work in the New Era Improve the pension services system. Proposing government-owned nursing home give priority to receive the low in-come people with dementia. Older adults 2022 The General Office of the State Council The 14th Five-Year Undertakings For The Aged And Elderly Service System plan (2020-2025) Establish a system framework for a national strategy to actively respond to ageing. Proposing public nursing home add special units for the care of the people with dementia, plus take actions to prevent and treat dementia, and provide psychological care. Older adults Financing system 2016 National Health Commission Document to perform pilot work for pension Establish and improve the policy framework for LTCI till 2020 Older adults Sources: Government publications. 2. Service delivery 2.1 Community and institution-based care services In 2011, the Chinese government proposed a roadmap to establish a three-tier LTC system, namely, home-based care as the basis, community-based services as backing, and institutional care as support (18) (Figure 2). Thus, community and institution-based care facilities are authorized to provide formal LTC services both in urban and rural areas (Table 2). These care facilities have a great diversity in proprietary, service population, service models, and cost. During the 13th Five-Year Plan period (2016-2020), LTC facilities providing community-based care and institutional care services for older adults increased from 0.116 million to 0.329 million, and the number of beds increased from 6.727 million to 8.21 million (19). Although these care facilities increased and improved access to health services for older people, no specialized professional care institutions for people with dementia. As the leading city for aim to build 10 day care centers for people with dementia, Qingdao city of the Shandong province, located in east China, has completed 8 of these centers, according to the government reported by August 2023 (20). How these institutions will operate in the future has not been reported. Table 2 Long-term care of community-based and institutional services in China Type Community-based services Institutional services Subtype Community centers in urban areas Community care pattern in rural areas Government-funded institutions Nursing homes Other residential care facilities Proprietary status Public facilities Public facilities Welfare facilities Public or private facilities Private sector accounts for the majority Service population Older adults Older adults Childless or without family older adults, orphans, mental health disorders or disabled people. Older adults Older adults Service content Community day care centers offered cooked meals, social activities, etc. Community health centers serve the healthcare needs of older adults with chronic illnesses. Older adults live in village housing where provide utilities and no service staff are employed, and they support each other. Provided with food, clothing, housing, medical care, and burial expenses. Most of them are found in urban areas and have professional staff. Provided with food, housing, and social activities. Provide personal care assistance and professional services. Cost payment Daycare services are offered free to individuals with a low-income or singletons. Others are provided services below market prices. Living expenses for people with a low income are covered by the government, while others pay for their costs privately. The charge is free, with a cash allowance provided. Charge according to a certain standard. Charge according to a certain standard. Sources: A review from Feng et al in 2020. 2.2 Healthcare services Nowadays, China’s healthcare system is composed of primary (including community hospitals), secondary (mainly regional hospitals), and tertiary (hospitals across provinces and cities) hospitals (7). The primary hospitals focus on outpatient services and chronic disease management, and secondary hospitals are concentration on providing inpatient, outpatient and emergency care (7). Additionally, the tertiary hospitals dedicated to mainly provide difficult and complex cases’ services (7). Health professionals working in public tertiary hospitals (i.e., neurology, psychiatric, and geriatric departments) are the main sources of diagnosis and treatment of dementia (21). Previous reports suggested that only 10% of people with dementia in China were diagnosed, of which was estimated approximately 70～80% have not received treatment (6, 22, 23). In 2015, China generated a National Mental Health Work Plan to focus on common mental disorders, and it reported there were 1,650 professional mental health institutions nationwide, 228,000 psychiatric beds, and more than 20,000 psychiatrists, mainly distributed at provincial and prefectural levels (24). 2.3 Integration of healthcare and long-term care services China has promoted the integration of healthcare and LTC services since 2015, and made it a new priority on the LTC policy agenda, aiming to integrate existing healthcare and LTC resources into a new old-age care model that integrates six functions, namely healthcare, rehabilitation, life services, leisure time activities, psychological care, and end-of-life care (25). It reported the number of the integration of healthcare and LTC institutions nationwide with two certificates (qualified as healthcare institutions and registered as care institutions) reached 5,857, and the number of beds reached 1.58 million in 2020 (19). Attracting, recruiting, and retaining staff in the LTC programs sector is an ongoing bottleneck problem for China due to poor career prospects (26). Even rural women, laid-off workers, and older people comprise most of the total China’s care workforce in the LTC programs, with limited educational levels, leading to more misunderstandings in the process of dementia care (26). Presently, most of these institutions lack the ability to combine healthcare with LTC services due to low quality of treatment and care skills. Hence, it is difficult to maintain the integration of healthcare and LTC services on the current trajectory. 3. Financing system 3.1 Healthcare insurance At present, China's healthcare insurance system is based on the principle of voluntary participation. The healthcare insurance coverage to 95.7% by 2011 across the country, and has been relatively stable since (27). In 2014, dementia was incorporated into the local basic healthcare insurance in the cities of Guangzhou, Taizhou, Chengdu, Zigong, and Urumqi for chronic disease management (28). Similar measures have been adopted by Jiangxi Province, Inner Mongolia Autonomous Region (28). However, there were no detailed implementation plans above regions. Additionally, people with dementia from other areas in China even do not benefit from healthcare insurance. 3.2 Long-term care insurance pilots In 2016, China launched long-term care insurance (LTCI) pilots in 15 cities for older adults, aiming at establishing and improving the policy framework for social LTCI till 2020 (29). These LTCI pilots were selected from different geographical regions, with variations in economic development, population aging, and fiscal capacities. Most pilots have a great diversity in many areas (Table 3), though they were based on the healthcare insurance system. Each pilot opts for its financing mechanism, types of welfare model, amounts of benefits, and eligibility rules. In addition to the criterion of age, each pilot set regulations regarding the disability level or dementia. Most pilots’ coverage was narrow and limited only to older people with the most serious degrees of disability, and excluded people with dementia. Many families are ineligible to participate in LTCI pilots, irrespective of their care needs. For example, Qingdao was the first pilot to launch the LTCI scheme in China, only less than 2% of the older population were covered by LTCI plans by the end of 2017, which included fewer people with dementia (30). In 2018, Chengdu (a city in western China) launched a policy indicating people with severe dementia were eligible for LTCI by assessing the situation of disability(31). Table 3 The summary of the broad features of the 15 LTCI pilots Item Type Pilot cities Population coverage Only urban employees Anqing, Chengde, Chengdu, Chongqing, Guangzhou, Ningbo, Qiqihar, Shangrao Urban employees and residents Changchun Urban employees and residents; rural residents Jingmen, Shihezi, Nantong, Qingdao, Suzhou, Shanghai Financing sources Basic Medical Insurance Changchun, Guangzhou, Ningbo, Shanghai Basic Medical Insurance and individual contribution Anqing, Chongqing, Qiqihar Basic Medical Insurance, government and individual contributions Chengde, Chengdu, Jingmen, Nantong, Qingdao Basic Medical Insurance and government subsidies Shihezi, Suzhou Basic Medical Insurance, plus government, individual, and employer contributions Shanghai Ages 60+ and disability (Evaluate based on self-designed scale) Shanghai Eligibility Severe disability Anqing, Changchun, Chengde, Chengdu, Chongqing, Jingmen, Nantong, Qiqihar, Shihezi Moderate or severe disability Suzhou Moderate or severe disability; dementia Guangzhou Severe disability; dementia Shangrao Disability (Evaluate based on self-designed scale); dementia Qingdao Service delivery Institutional care Changchun, Ningbo Institutional and home care Anqing, Chengde, Chengdu, Chongqing, Guangzhou, Jingmen, Nantong, Qingdao, Qiqihar, Shangrao, Shihezi, Suzhou Institutional, community and home care Shanghai Benefits Care services Changchun, Chengde, Chengdu, Chongqing, Guangzhou, Ningbo, Qiqihar, Jingmen, Qingdao, Suzhou, Shanghai Care services and cash allowance (CNY 15,25 or 40 per day) Anqing, Shihezi, Nantong, Shangrao Sources: Government publications on LTCI. Notes: Basic Medical Insurance: the urban employee basic medical insurance scheme (UEBMI), the urban resident basic medical insurance scheme (URBMI), and the new rural cooperative medical system (NRCMS) for rural residents. Disability is based on the Barthel Index, which categorizes their levels of independence into four types: severe disability (score: 0–40), moderate disability (score: 41–60), mild disability (score: 61–99), or full independence (score: 100). Issues and challenges China's traditional LTC system that heavily relies on families is eroding. In the past ten years or more, the development of the LTC services policy of dementia in China, to some extent, has reflected both the attention and policy efforts by the government. Consequently, the challenges of the LTC system for people with dementia have received growing attention in China. 1. No specificity and continuity in policy Indeed, to date, LTC services for people with dementia in China are included in the “fragmentation” policies with no specific guidance or an action plan. The fragmentation policies involve three aspects. The first is the fragmentation of government institutions. China currently yet has a national LTC management organization, resulting in departmental segmentation, affecting the actual implementation effect of policies (32). The second is the fragmentation of service institutions. Scientific and specific evaluation of the LTC access mechanism for people with dementia is lacking. There is no specific classification and management of care for dementia. Most care facilities and LTCI pilots regard dementia as a disability, mixing dementia patients with disabled older adults, and few detailed criteria differentiating the status of actual care needs for people with dementia. The third is the fragmentation of policy functions. Scientific standards and national norms of LTC-qualified personnel and professional educational programmers for people with dementia are inadequate. Shortage of scientific and valid information systems with oversight, management, and quality control, making it fail to estimate the level and quality of institutions and communities' LTC services for people with dementia. Overall, the untargeted and discontinuities in policy lead to the low availability of LTC services to people with dementia in China. 2. Professional workforce shortage and improper allocation In all countries with an aging population, the workforce needed to provide all types of LTC in a variety of settings is neither large enough nor adequately trained to meet the needs (33). The main workforce shortage is mental health professionals in China. First, the low number of dementia doctors in neurology, psychiatry, or geriatric departments and hospitals led to low diagnosis and treatment of dementia (34). Second, China's healthcare service resources are improperly allocated (24), which is another reason why the diagnosis and management are still low and inadequate, especially in rural areas (35). Currently, the prevalence of dementia is substantially higher in rural areas than in urban (7), and in northern China than in southern (36). Instead, dementia sufferers in rural areas, especially those residing in northern areas, have not been diagnosed or received professional treatment and care due to limited affordable access to healthcare resources which has led to lower rates of diagnosis and treatment (37), despite the dementia diagnosis rate in other urban areas is still less than 30% (38). Another workforce shortage is professional care workers. Professionals with professional knowledge of medicine, psychology, physiology, and sociology also have a huge gap. To alleviate the shortage of care workers, the Chinese government has made major modifications in relaxing the entry conditions, broadening the career development space, shortening the time for professional skill level promotion, and carrying out professional training (39)Moreover, the governments of Guangdong Province, Jiangsu Province, and Shanghai adopted entry subsidy measures to enhance occupational attractiveness (40). However, community-based care services are difficult to effectively meet the needs of people with dementia for professional care such as security and cognitive training (41, 42). Similarly, China’s institutional care is underserved in high-level care and overall support for people with dementia because of highly complex and differ in terms of organizational characteristics (e.g. proprietary status, size of unit), processes (access to specialized dementia care, case management, or palliative care), and structures of care (hours of care provided per resident, level of expertise, or diversity of workforce) (43). Over 60 % of the care institutions had no professional nursing staff to meet the demand of LTC in rural China (44). Thus, given the increasing need for dementia care in China, the inadequacy of professionals in dementia and dementia care services is the major barrier to improving the quality of care, leading to the LTC services being more difficult to come true. 3. Inconsistent design in financing source and eligibility The LTCI pilots and healthcare insurance may play a role in alleviating the social burden of dementia to some extent and improving the quality of life for people with dementia. However, the coverage of LTCI and basic medical insurance for dementia is too narrow (28, 32). Currently, only three cities, Guangzhou, Qingdao, and Shangrao, expand LTCI coverage to people with dementia. However, some organizations receive dementia benefits for very few people in these cities, for instance, a study suggested that 4582 obtained LTCI benefits in the pilot of Guangzhou, but only 791 (17.3%) people with dementia were covered (45). Moreover, people with dementia have been included in the reimbursement scope of chronic disease management in local basic medical insurance outpatient clinics in some areas, which is only implemented in urban areas (28), so most people with dementia cannot be covered. Therefore, there are problems in the insured scope, fund pooling, eligibility rules, and supply standard, and lack of a unified evaluation system in the LTCI pilots and healthcare insurance, and dementia patients with the same health status in different regions are unable to gain the same services. Discussion and recommendations The continuous increase in China’s dementia population and the public LTC system that currently only benefits a relatively narrow and small group of people with dementia, leaving many huge gaps of unmet needs. To address this situation, China’s strategy for the LTC system for dementia is developing; however, the strategy has yet to develop specific and continued policy. The deficiency of specificity and continuity in the policy of dementia is a major barrier to effective supervision and management of the allocation of mental health services and professional care workforce, and evaluation of the quality of care and integration of the services criteria. We hereby make policy recommendations in several high-priority areas, drawing on international experiences. 1. Issuing a national strategic plan for stewardship, financing, and regulation Politically, adopting strategies to promote health and welfare for people with dementia is most powerful and essential at the national level. The formal LTC for dementia has always been contained in healthcare services of national plans in many countries. For example, Italy and France have bespoke dementia evaluation units around the country, and UK has emphasized dementia as a national priority of health plans and recorded much success in increasing the diagnosis rate (46) . Austria, Canada, and Japan have launched a national dementia strategy to address the scale, impact, and cost of dementia, to support its implementation, would ensure that people with dementia have access to services (47-49). Besides, three types of financing sources emerged when Japan, Germany, and South Korea instituted LTCI for dementia, which are tax revenues, social insurance, and copayments from individuals (50). Similarly, both Germany and Japan assess care levels under specific guidelines (50). China has yet issued a national strategic plan for dementia. The LTCI pilots and healthcare insurance fill a much-needed gap in public support for LTC of dementia in China. Yet, much work remains to be done. Currently, few beneficiaries due to strict eligibility criteria. Particularly, most participants of people with dementia are more often ineligible for benefits due to most of the pilots and healthcare insurance completely excluding the dementia population. A multifaceted strategy is recommended for strengthening the welfare of people with dementia in China. First, the government should confirm the issue of care for people with dementia in the first place and the recognition of dementia as a public health priority, as seen in the cases of other countries. More monitoring criteria must be created on the public agenda to meet the needs of people with dementia, particularly in rural areas. Second, policymakers need to through tax revenues as a way to increase the financing and equity in the system to improve people with dementia to access LTC and address the challenges of limited personal coverage, rural-urban disparities in access to LTC services, and uneven access to a certain support. Then, out-of-pocket payments should be utilized as an essential tool to curb moral hazard and prevent overutilization of services, as in the systems of Korea and Japan (50). Third, the central government should provide grants to local governments to significantly increase the supply of LTC providers according to set targets, which are lessons learned from the Japanese LTCI system. Additionally, the implementation of assessing care levels under specific guidelines is crucial to people with dementia. 2. Developing the professional workforce Improving the training and education of professionals working with people with dementia is a priority in the national plans of several countries. Strategies are emerging in some countries. Early diagnosis of dementia is the important first step for accessing services. Experts support that people with dementia can be identified using case-finding approaches that target individuals at high risk in community and primary care settings (51). For example, Australia, Canada, the USA, and the UK have published guidelines for the diagnosis and management of dementia in primary care settings, such as employing Registered Nurses (RN), nurse practitioners (NP), and General Practitioners (GP) as dementia care experts in primary care settings, to encourage earlier detection and diagnosis (46, 52-54). Furthermore, both Canada and the US emphasized that taking collaboration between health providers, professional organizations, and professional licensing bodies to develop a dementia care workforce (47, 55). Thus, strategies are needed in China to increase the number of health professionals to deal with the influx of people with dementia. Primary healthcare is the first level of contact that individuals, families, and communities have with the healthcare system. Unfortunately, the majority of China’s GP had low levels of recognition of roles for dementia care and believed that dementia care was within a specialist’s domain, not that of general practice (52). Therefore, carrying out some national policies in China to train primary care professionals involved in making dementia diagnosis curial, such as the GP, who is often the first physician to observe patients with possible dementia (56), and to overall improve the level of their services towards dementia care. Additionally, owing to the disproportionate economic development in the coastal regions of China as compared with the inland regions, there is an equally uneven spatial distribution of social resources for LTC (57). Thus, national dementia policies also need to consider how key contextual factors such as poverty, inequality, and limited resources, impact the health of the population and access to health services (58). Furthermore, China’s government should introduce policies to develop an effective LTC professional care workforce regulatory framework and quality assurance system. On the demand side, strategies for improving knowledge and skills in dementia care is crucial for all care worker, especially for formal care. This improvement in care requires identifying the problems of the caregivers’ motivations, work conditions, and dementia education and training needs. On the supply side, evidence-based practices of effective care are essential. Policymakers should leverage the available results of evidence-based practices and policy instruments, to execute a scheme for adequate supply, distribution, and utilization of health providers. Meanwhile, using health providers working cooperation as a strategy to expand the capacity of the healthcare system in teams for meeting professional care and to respond to the growing needs of people with dementia is critical. 3. Delivering person-centered care services Person-centered care is considered integral in providing high-quality care for people with dementia in several countries, such as Dementia Friendly Community (DFC) and Palliative Care (PC). DFC are proposed to empower and support people affected by dementia and their careers in society, understand their rights, and recognize their full potential (59). DFC is critically important for those who wish to remain in their homes with our wide range of services including caregiver support and adult day care which are less costly than institutional care services. Consequently, DFC has been developed not only in Europe but also in Asian countries. For example, the UK is putting DFC on the policy agenda and becoming one of the first countries in the world committed to being a DFC (60). Japan and the US also have established a strategy for creating DFC. Moreover, evidence suggests that covering Palliative Care (PC) for dementia is important. PC is broadly recognized as an essential model for providing effective, comprehensive, and transdisciplinary care for dementia (61). China’s system of formal LTC for people with dementia is in the preliminary stage. Not only the availability of community-based health services related to dementia LTC in short supply, but most nursing institutions also find it difficult to provide LTC services for people with dementia (26). Thus, China should establish a sound mental LTC services system and network, with specialized dementia health institutions as the main body, psychiatric units in general hospitals as auxiliary units, and community medical and health institutions for mental diseases as the foundation. The government should improve the community and institutional care services, and identify the need for sufficient training. On the one hand, policy and resource development to meet the demand for community and institutional dementia care services, is urgently needed, such as advancing the setup of DFC promoting PC as a policy agenda, and supporting essential resources. On the other hand, understanding how different care settings, such as nursing homes, bring their opportunities and challenges, including staff issues, workflow, and use policies, with dementia being a target of a nationwide program to reduce usage. 4. Prospects for future research Given the challenges posed by the increasing number of people with dementia, tackling the looming dementia crisis is simply insufficient. Based on this critical analysis, several warrant additional research we suggest. First, a better understanding of current LTC demand and supply is crucial to inform policy planning, resource allocation, and workforce reinforcing towards developing an effective and sustainable LTC that would meet the demands of the continuously increasing dementia population. Second, given the persistent urban-rural disparities in China, more research is needed to understand the gaps and inequalities in LTC needs and resources between people with dementia in urban and rural areas, to meet LTC needs for people with dementia all-around and narrow urban–rural divided. Third, as China progresses with the LTCI pilots and the combination of medical care and pension, it is essential to do rigorous independent evaluations before upscaling them. Conclusions With China’s aging population and deteriorating health, a strong and accessible LTC system is vital to keep people with dementia well and out of the hospital. The looming dementia crisis has penetrated the consciousness of clinicians, researchers, policymakers, politicians, and the public at large. Overall, the vitality of the dementia service market has yet to be fully stimulated, problems such as unbalanced and inadequate development, insufficient effective supply, and low service quality still exist, and the LTC services needs for people with dementia have yet to be effectively met. The official policy, however, is still developing. Lessons from international experiences that are may able to help China conduct novel health policy, to offer a comprehensive set of services for people with dementia. It is urgent to establish a unified national LTC services system to promote the healthy development of care services for people with dementia. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials Not applicable. Competing interests The authors declare that there is no conflict of interest. Funding None. Authors' contributions HC designed the study; HC and LL acquired, analyzed, interpreted of data; HC drafted the manuscript; HC,LL and XH revised manuscript. All authors have read and approved the final manuscript. Acknowledgement Not applicable. References National Bureau of Statistics. https://data.stats.gov.cn/easyquery.htm?cn=C01&zb=A0303&sj=2022. Accessed 01 Mar 2023. . GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019;18(5):459-80. Elahi FM, Miller BL. A clinicopathological approach to the diagnosis of dementia. Nature reviews Neurology. 2017;13(8):457-76. Jutten RJ, Harrison JE, Lee Meeuw Kjoe PR, Ingala S, Vreeswijk R, van Deelen RAJ, et al. 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Dementia prevention, intervention, and care. Lancet (London, England). 2017;390(10113):2673-734. Wang J, Wang Y, Cai H, Zhang J, Pan B, Bao G, et al. Analysis of the status quo of the Elderly's demands of medical and elderly care combination in the underdeveloped regions of Western China and its influencing factors: a case study of Lanzhou. BMC Geriatr. 2020;20(1):338. Wu J, Chen S, Wen H, Yi Y, Liao X. Health status, care needs, and assessment for beneficiaries with or without dementia in a public long-term care insurance pilot in Guangzhou, China. BMC Health Serv Res. 2020;20(1):1127. Burns A, Robert P, group Is. Dementia care: international perspectives. Curr Opin Psychiatry. 2019;32(4):361-5. Boscart VM, McNeill S, Grinspun D. Dementia Care in Canada: Nursing Recommendations. Can J Aging. 2019;38(3):407-18. Plunger P, Heimerl K, Tatzer VC, Zepke G, Finsterwald M, Pichler B, et al. Developing dementia-friendly pharmacies in Austria: a health promotion approach. Health promotion international. 2020;35(4):702-13. Wammes JD, Nakanishi M, van der Steen JT, MacNeil Vroomen JL. Japanese National Dementia Plan Is Associated with a Small Shift in Location of Death: An Interrupted Time Series Analysis. Journal of Alzheimer's disease : JAD. 2021;83(2):791-7. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health policy (Amsterdam, Netherlands). 2015;119(10):1319-29. Wübbeler M, Thyrian JR, Michalowsky B, Erdmann P, Hertel J, Holle B, et al. How do people with dementia utilise primary care physicians and specialists within dementia networks? Results of the Dementia Networks in Germany (DemNet-D) study. Health Soc Care Community. 2017;25(1):285-94. Wang M, Xu X, Huang Y, Shao S, Chen X, Li J, et al. Knowledge, attitudes and skills of dementia care in general practice: a cross-sectional study in primary health settings in Beijing, China. BMC Fam Pract. 2020;21(1):89. Galvin JE, Sadowsky CH. Practical guidelines for the recognition and diagnosis of dementia. Journal of the American Board of Family Medicine : JABFM. 2012;25(3):367-82. Fortinsky RH, Delaney C, Harel O, Pasquale K, Schjavland E, Lynch J, et al. Results and lessons learned from a nurse practitioner-guided dementia care intervention for primary care patients and their family caregivers. Research in gerontological nursing. 2014;7(3):126-37. Weiss J, Tumosa N, Perweiler E, Forciea MA, Miles T, Blackwell E, et al. Critical Workforce Gaps in Dementia Education and Training. J Am Geriatr Soc. 2020;68(3):625-9. van Hout HP, Vernooij-Dassen MJ, Stalman WA. Diagnosing dementia with confidence by GPs. Family practice. 2007;24(6):616-21. Liu T, Sun L. An apocalyptic vision of ageing in China: Old age care for the largest elderly population in the world. Z Gerontol Geriatr. 2015;48(4):354-64. Hojman DA, Duarte F, Ruiz-Tagle J, Budnich M, Delgado C, Slachevsky A. The cost of dementia in an unequal country: The case of Chile. PloS one. 2017;12(3):e0172204. Norton MJ, Allen RS, Snow AL, Hardin JM, Burgio LD. Predictors of need-driven behaviors in nursing home residents with dementia and associated certified nursing assistant burden. Aging & mental health. 2010;14(3):303-9. Buckner S, Mattocks C, Rimmer M, Lafortune L. An evaluation tool for Age-Friendly and Dementia Friendly Communities. Work Older People. 2018;22(1):48-58. Stewart JT, Schultz SK. Palliative Care for Dementia. The Psychiatric clinics of North America. 2018;41(1):141-51. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4263935","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293499909,"identity":"d45832e0-d4af-450c-a07c-5f4b5eabca95","order_by":0,"name":"Haiyan Chong","email":"","orcid":"","institution":"Innovation Center of Nursing Research and West China School of Nursing, West China Hospital, Sichuan University/Institute for Disaster Management and Reconstruction, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Haiyan","middleName":"","lastName":"Chong","suffix":""},{"id":293499910,"identity":"34eb24cb-7c0b-4bbd-8692-2ad39f2b3012","order_by":1,"name":"Li Liu","email":"","orcid":"","institution":"Innovation Center of Nursing Research and West China School of Nursing, West China Hospital, Sichuan University/Institute for Disaster Management and Reconstruction, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Liu","suffix":""},{"id":293499911,"identity":"caf6d7f3-515f-40c2-b6ff-49a782f3bb97","order_by":2,"name":"Xiuying Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACAyA+wMAgwcDA3gAWYGwgXgvPARK0QIBEApFazCVyDA/ztlnkyUc+f/iZh8FGdsMB5mcP8GmxnJGWANQiUWx4O8dYmochzXjDATZzA3xaDG4kHwBpSdw4O4eNmYfhcOKGAzxsEvi1JDZAtMw8/gyo5T8xWqC2zJdgMANqOUCEljPPEg7OOSeRuIEnx1hyjkGy8czDbGb4tRzPMf7wpqwucX778Ycf3lTYyfYdb36GVwsYMLIB9R4AmwDEzATVg8AfBgb5BqJUjoJRMApGwUgEANBjSkFkGjDYAAAAAElFTkSuQmCC","orcid":"","institution":"Innovation Center of Nursing Research and West China School of Nursing, West China Hospital, Sichuan University/Institute for Disaster Management and Reconstruction, Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Xiuying","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2024-04-14 07:14:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4263935/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4263935/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55080141,"identity":"d8c4de84-bbd5-4a09-ab8d-80c04eee12e3","added_by":"auto","created_at":"2024-04-22 09:34:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":165248,"visible":true,"origin":"","legend":"\u003cp\u003eThe overview of the long-term care system for dementia.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4263935/v1/3c077523fc7aab1423a794dd.png"},{"id":55080140,"identity":"6c536801-2557-4113-88ca-d03af9f2f5f6","added_by":"auto","created_at":"2024-04-22 09:34:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82912,"visible":true,"origin":"","legend":"\u003cp\u003eThe overview of the types of three-tier long-term care system.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4263935/v1/959f7c761b4ba76beb1bc55b.png"},{"id":86917449,"identity":"cf86a11a-f157-461f-81d4-3883702c1b0e","added_by":"auto","created_at":"2025-07-17 06:54:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":987827,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4263935/v1/5e317e9f-7be7-4732-b4d9-9eea268a321d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term care system for people with dementia in China: A critical analysis","fulltext":[{"header":"Background","content":"\u003cp\u003ePopulation aging is a global challenge. In China, 209.78 million adults were 65 years or older in 2022, representing 14.90% of the country’s\u0026nbsp;population\u0026nbsp;(1).\u0026nbsp;As the leading cause of disability for the older population\u0026nbsp;(2), dementia involving the disruption of functional networks underlying cognition, personality, behavior, and sensorimotor, eventually attacking an individual’s autonomy\u0026nbsp;(3). Dementia increases with age\u0026nbsp;(4), which is the fourth leading cause of death amongst adults over 65 years in China\u0026nbsp;(5). With the prevalence rising from 5.14 % in 2014\u0026nbsp;(6)\u0026nbsp;to 5.60 % in 2019 amongst people 65 years or older\u0026nbsp;(7), Chinese people with dementia account for approximately a quarter of the global burden of diseases\u0026nbsp;(8). The rapid increase of people with dementia led to enormous social and economic consequences\u0026nbsp;(9).\u0026nbsp;In China, dementia costed 1.47% of the country’s gross domestic product (GDP) in 2015, larger than the global average of 1.09%\u0026nbsp;(10).\u003c/p\u003e\n\u003cp\u003eDementia adversely affects health and well-being. People with dementia are more likely to suffer cognitive impairment, hallucinations, delusions, and severely impaired social functioning\u0026nbsp;(3). There is currently no cure for dementia, with the life expectancy for people with dementia lasting 8 to 10 years as a consequence\u0026nbsp;(8). Additionally, more than 1,370 people aged 60 or older lose their bearings and go missing every day, according to the China White Paper on the Lost Elderly, dementia and lack of care services were cited as the leading factors in the disappearances\u0026nbsp;(11). Thus, the need for LTC is common for People with dementia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTraditionally, the Chinese provide LTC to older people within families. However, China’s rapid demographic shifts were exacerbated by the one-child policy, and have made such duties increasingly difficult to fulfill. Growing burdens are borne on the public healthcare system, resulting in important implications for the LTC system\u0026nbsp;(12). Analyzing current policy system, challenges, and\u0026nbsp;offering recommendations of China's LTC for People with dementia can help the government for practicing and policy decisions, thereby improving People with dementia’ well-being in the future.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this\u0026nbsp;paper, we focus on the care for people with dementia in the Chinese mainland,\u0026nbsp;we use\u0026nbsp;long-term care (LTC) to describe the scope of formal care and services in support of people with dementia.\u0026nbsp;We describe China’s policy system for dementia and analyze issues and challenges in building its LTC service system for people with dementia based on government reports, news, literature reviews, and studies during 2010-2023.\u0026nbsp;Lessons from the international long-term care experiences for dementia, we offer policy recommendations to improve and strengthen the long-term care system for people with dementia in China.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eWe will make a systematic and comprehensive critical analysis of the policy system based on lots of government reports, news,\u0026nbsp;and literature of the LTC system for people with dementia in China.\u003c/p\u003e\n\u003cp\u003eWe searched the PubMed, Web of Sciences, and CNKI database to identify original and review articles in English and Chinese language. Moreover, we surf previous government reports and news looking for information on China’s LTC system for dementia, to we deliver the detailed description for performing a critical analysis. The keywords used were long-term care, dementia, China. Relevant articles, government reports and news published between 2010 and August 2023 were critically reviewed, analyzed, and summarized.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eChina\u0026rsquo;s LTC system for dementia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSimilar to other countries, LTC services in China are supplemented by formal (paid) care, such as welfare homes, nursing homes, community-based day-care centers, household assistants, community hospitals, and so on. We described China\u0026rsquo;s LTC system for dementia from three overarching aspects: governance and policy, service delivery, and the system of financing (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Governance and policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1 Governance structure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn China, the National Bureau of Statistics is responsible for national economic,\u0026nbsp;workforce employment, social development, and service industry statistics, and the census\u0026nbsp;(13). The Ministry of Health, namely, the National Health Commission, takes charge of information on health system resources, public health services, drug management, food safety, and population health surveillance et.al\u0026nbsp;(14). The National Healthcare Security Administration is responsible for information that are related to social health insurance, medical assistance, and drug tendering\u0026nbsp;(15).\u0026nbsp;The Ministry of Civil Affairs is responsible for the formulation and implementation of the pension service system, and the welfare and assistance of the older adults\u0026nbsp;(16). The National Medical Products Administration is responsible for information on the approval, and manufactural records of drugs and medical equipment\u0026nbsp;(17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e \u003cstrong\u003ePolicy development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn recent years, efforts have been made by the Chinese government to increase benefits for older adults. Thus, relevant supporting policies also have been issued to improve the supply of LTC services for\u0026nbsp;people with dementia(Table 1).\u0026nbsp;However, most policies for dementia in China still are just mentioned with a simple proposal or overview; even people with dementia are only included under the category of disabled older adults. Currently, no specific and overall planning and implementation were implied, leading to dementia and its associated problems have been not directly addressed in China\u0026rsquo;s policy.\u0026nbsp;The\u0026nbsp;policy system in China for dementia still faces the challenge of population aging and inefficient delivery on the side of the supply, growing burdens are borne on\u0026nbsp;both health expenditures and individual disease.\u003c/p\u003e\n\u003cp\u003eTable 1 Policy development in LTC for dementia in China 2010-2023\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"674\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.589895988112927%\" valign=\"top\"\u003e\n \u003cp\u003ePolicy dimensions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.240713224368499%\" valign=\"top\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.413075780089153%\" valign=\"top\"\u003e\n \u003cp\u003ePolicy body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.61367013372957%\" valign=\"top\"\u003e\n \u003cp\u003eDocument title\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.906389301634473%\" valign=\"top\"\u003e\n \u003cp\u003eMain content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.236255572065378%\" valign=\"top\"\u003e\n \u003cp\u003ePolicy object\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.589895988112927%\" rowspan=\"7\"\u003e\n \u003cp\u003eService system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.240713224368499%\" valign=\"top\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.413075780089153%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.61367013372957%\" valign=\"top\"\u003e\n \u003cp\u003eNational plan for the development of pension services and system (2011-2015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.906389301634473%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish the three-tier LTC system to facilitate LTC \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.236255572065378%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eNational Mental Health Work Plan (2015-2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003eFocus on common mental disorders (including dementia), and improve \u0026nbsp; preventive and treatable mode\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003ePeople with mental disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eGuidance to promote the combination of medical care and LTC services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish and improve the mechanism to combine medical institutions with nursing home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eThe 13th Five-Year Healthy Ageing Plan (2016-2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003ePopularizing health and care services for individuals. Planning to strengthen the dementia prevention and service supply system.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eDocument to promote the development of pension services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish and improve the policy framework for pension on managing, funding, workforce and the quality of services. Stressing government-owned and public nursing home provide free or less charge care services for low in-come people with dementia.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eDocument to strengthen ageing work in the New Era\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003eImprove the pension services system. Proposing government-owned nursing home give priority to receive the low in-come people with dementia.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.0588235294117645%\" valign=\"top\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.30252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eThe General Office of the State Council\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.18487394957983%\" valign=\"top\"\u003e\n \u003cp\u003eThe 14th Five-Year Undertakings For The Aged And Elderly Service System plan (2020-2025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95798319327731%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish a system framework for a national strategy to actively respond to ageing. Proposing public nursing home add special units for the care of the people with dementia, plus take actions to prevent and treat dementia, and provide psychological care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.49579831932773%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.589895988112927%\" valign=\"top\"\u003e\n \u003cp\u003eFinancing system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.240713224368499%\" valign=\"top\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.413075780089153%\" valign=\"top\"\u003e\n \u003cp\u003eNational Health Commission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.61367013372957%\" valign=\"top\"\u003e\n \u003cp\u003eDocument to perform pilot work for pension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.906389301634473%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish and improve the policy framework for LTCI till 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.236255572065378%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSources: Government publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Service delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Community and institution-based care services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 2011, the Chinese government proposed a roadmap to establish a three-tier LTC system, namely, home-based care as the basis, community-based services as backing, and institutional care as support (18) (Figure 2). Thus, community and institution-based care facilities are authorized to provide formal LTC services both in urban and rural areas (Table 2). These care facilities have a great diversity in proprietary, service population, service models, and cost. During the 13th Five-Year Plan period (2016-2020), LTC facilities providing community-based care and institutional care services for older adults increased from 0.116 million to 0.329 million, and the number of beds increased from 6.727 million to 8.21 million (19). Although these care facilities increased and improved access to health services for older people, no specialized professional care institutions for people with dementia. As the leading city for aim to build 10 day care centers for people with dementia, Qingdao city of the Shandong province, located in east China, has completed 8 of these centers, according to the government reported by August 2023 (20). How these institutions will operate in the future has not been reported.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Long-term care of community-based and institutional services in China\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"681\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.32599118942731%\" colspan=\"2\"\u003e\n \u003cp\u003eCommunity-based services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.220264317180614%\" colspan=\"3\"\u003e\n \u003cp\u003eInstitutional services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eSubtype\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.411160058737153%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity centers in urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.91483113069016%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity care pattern in rural areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.32745961820852%\" valign=\"top\"\u003e\n \u003cp\u003eGovernment-funded institutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eNursing homes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eOther residential care facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eProprietary status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.411160058737153%\" valign=\"top\"\u003e\n \u003cp\u003ePublic facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.91483113069016%\" valign=\"top\"\u003e\n \u003cp\u003ePublic facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.32745961820852%\" valign=\"top\"\u003e\n \u003cp\u003eWelfare facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003ePublic or private facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003ePrivate sector accounts for the majority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eService population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.411160058737153%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.91483113069016%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.32745961820852%\" valign=\"top\"\u003e\n \u003cp\u003eChildless or without family older adults, orphans, mental health disorders or disabled people.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eService content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.411160058737153%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity day care centers offered cooked meals, social activities, etc. Community health centers serve the healthcare needs of older adults with chronic illnesses.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.91483113069016%\" valign=\"top\"\u003e\n \u003cp\u003eOlder adults live in village housing where provide utilities and no service staff are employed, and they support each other.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.32745961820852%\" valign=\"top\"\u003e\n \u003cp\u003eProvided with food, clothing, housing, medical care, and burial expenses.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eMost of them are found in urban areas and have professional staff. Provided with food, housing, and social activities.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eProvide personal care assistance and professional services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"top\"\u003e\n \u003cp\u003eCost payment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.411160058737153%\" valign=\"top\"\u003e\n \u003cp\u003eDaycare services are offered free to individuals with a low-income or singletons. Others are provided services below market prices.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.91483113069016%\" valign=\"top\"\u003e\n \u003cp\u003eLiving expenses for people with a low income are covered by the government, while others pay for their costs privately.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.32745961820852%\" valign=\"top\"\u003e\n \u003cp\u003eThe charge is free, with a cash allowance provided.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eCharge according to a certain standard.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.44640234948605%\" valign=\"top\"\u003e\n \u003cp\u003eCharge according to a certain standard.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSources: A review from Feng et al in 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Healthcare services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNowadays, China\u0026rsquo;s healthcare system is composed of primary (including community hospitals), secondary (mainly regional hospitals), and tertiary (hospitals across provinces and cities) hospitals\u0026nbsp;(7).\u0026nbsp;The primary hospitals focus on outpatient services and chronic disease management, and secondary hospitals are concentration on providing inpatient, outpatient and emergency care\u0026nbsp;(7).\u0026nbsp;Additionally,\u0026nbsp;the tertiary hospitals dedicated to mainly provide difficult and complex cases\u0026rsquo; services\u0026nbsp;(7). Health professionals working in public tertiary hospitals (i.e., neurology, psychiatric, and geriatric departments) are the main sources of diagnosis and treatment of dementia\u0026nbsp;(21). Previous reports suggested that only 10% of people with dementia in China were diagnosed, of which was estimated approximately 70～80% have not received treatment\u0026nbsp;(6, 22, 23). In 2015, China generated a National Mental Health Work Plan to focus on common mental disorders, and it reported there were 1,650 professional mental health institutions nationwide, 228,000 psychiatric beds, and more than 20,000 psychiatrists, mainly distributed at provincial and prefectural levels\u0026nbsp;(24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntegration of healthcare and long-term care services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChina has promoted the integration of healthcare and LTC services since 2015, and made it a new priority on the LTC policy agenda, aiming to integrate existing healthcare and LTC resources into a new old-age care model that integrates six functions, namely healthcare, rehabilitation, life services, leisure time activities, psychological care, and end-of-life care\u0026nbsp;(25).\u0026nbsp;It reported\u0026nbsp;the number of the integration of healthcare and\u0026nbsp;LTC institutions nationwide with two certificates (qualified as healthcare institutions and registered as\u0026nbsp;care institutions) reached 5,857, and the number of beds reached 1.58 million in 2020\u0026nbsp;(19).\u0026nbsp;Attracting, recruiting, and retaining staff in the LTC programs sector is an ongoing bottleneck problem for China due to poor career prospects\u0026nbsp;(26).\u0026nbsp;\u0026nbsp;Even rural women, laid-off workers, and older people comprise most of the total China\u0026rsquo;s care workforce in the LTC programs, with limited educational levels, leading to more misunderstandings in the process of dementia care\u0026nbsp;(26).\u0026nbsp;Presently, most of these institutions lack the ability to combine healthcare with\u0026nbsp;LTC services due to low quality of treatment and care skills. Hence, it is difficult to maintain the integration of healthcare and LTC services on the current trajectory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Financing system\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Healthcare insurance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt present, China\u0026apos;s healthcare insurance\u0026nbsp;system is based on the principle of voluntary participation. The healthcare insurance coverage to 95.7% by 2011\u0026nbsp;across the country, and has been relatively stable since\u0026nbsp;(27). In 2014, dementia was incorporated into the local basic healthcare insurance in the cities of Guangzhou, Taizhou, Chengdu, Zigong, and Urumqi for chronic disease management\u0026nbsp;(28). Similar measures have been adopted by Jiangxi Province, Inner Mongolia Autonomous Region\u0026nbsp;(28). However, there were no detailed implementation plans above regions. Additionally, people with dementia from other areas in China even do not benefit from healthcare insurance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Long-term care insurance pilots\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn\u0026nbsp;2016, China launched long-term care insurance (LTCI) pilots in 15 cities for older adults, aiming at establishing and improving the policy framework for social LTCI till 2020\u0026nbsp;(29).\u0026nbsp;These LTCI\u0026nbsp;pilots were selected from different geographical regions, with variations in economic development, population aging, and fiscal capacities. Most pilots have a great diversity in many areas\u0026nbsp;(Table 3), though\u0026nbsp;they were\u0026nbsp;based on the healthcare insurance system. Each pilot opts for its financing mechanism, types of welfare model,\u0026nbsp;amounts of benefits, and eligibility rules. In addition to the criterion of age, each pilot set regulations regarding the disability level or dementia.\u0026nbsp;Most pilots\u0026rsquo; coverage was narrow and limited only to older people with the most serious degrees of disability, and excluded people with dementia. Many families are ineligible to participate in LTCI pilots, irrespective of their care needs. For example, Qingdao was the first pilot to launch the LTCI scheme in China, only less than 2% of the older population were covered by LTCI plans by the end of 2017,\u0026nbsp;which included fewer people with dementia\u0026nbsp;(30). In 2018, Chengdu (a city in western China) launched a policy indicating people with severe dementia were eligible for LTCI by assessing the situation of disability(31).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 The summary of the broad features of the 15 LTCI pilots\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"634\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" valign=\"top\"\u003e\n \u003cp\u003eItem\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003ePilot cities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003cp\u003ecoverage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eOnly urban employees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003eAnqing, Chengde, Chengdu, Chongqing, Guangzhou, Ningbo, Qiqihar, Shangrao\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eUrban employees and residents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eChangchun\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eUrban employees and residents; rural residents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eJingmen, Shihezi, Nantong, Qingdao, Suzhou, Shanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eFinancing sources\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Medical Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003eChangchun, Guangzhou, Ningbo, Shanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Medical Insurance and individual contribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eAnqing, Chongqing, Qiqihar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Medical Insurance, government and individual contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eChengde, Chengdu, Jingmen, Nantong, Qingdao\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Medical Insurance and government subsidies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eShihezi, Suzhou\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eBasic Medical Insurance, plus government, individual, and employer contributions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eShanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eAges 60+ and disability (Evaluate based on self-designed scale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eShanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eEligibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eSevere disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003eAnqing, Changchun, Chengde, Chengdu, Chongqing, Jingmen, Nantong, Qiqihar, Shihezi\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eModerate or severe disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eSuzhou\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eModerate or severe disability; dementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eGuangzhou\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eSevere disability; dementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eShangrao\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eDisability (Evaluate based on self-designed scale); dementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eQingdao\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eService delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eInstitutional care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003eChangchun, Ningbo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eInstitutional and home care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eAnqing, Chengde, Chengdu, Chongqing, Guangzhou, Jingmen, Nantong, Qingdao, Qiqihar, Shangrao, Shihezi, Suzhou\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eInstitutional, community and home care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eShanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.848341232227488%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBenefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.86255924170616%\" valign=\"top\"\u003e\n \u003cp\u003eCare services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.28909952606635%\" valign=\"top\"\u003e\n \u003cp\u003eChangchun, Chengde, Chengdu, Chongqing, Guangzhou, Ningbo, Qiqihar, Jingmen, Qingdao, Suzhou, Shanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.086021505376344%\" valign=\"top\"\u003e\n \u003cp\u003eCare services and cash allowance (CNY 15,25 or 40 per day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.913978494623656%\" valign=\"top\"\u003e\n \u003cp\u003eAnqing, Shihezi, Nantong, Shangrao\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSources: Government publications on LTCI. Notes: Basic Medical Insurance: the urban employee basic medical insurance scheme (UEBMI), the urban resident basic medical insurance scheme (URBMI), and the new rural cooperative medical system (NRCMS) for rural residents. Disability is based on the Barthel Index, which categorizes their levels of independence into four types: severe disability (score: 0\u0026ndash;40), moderate disability (score: 41\u0026ndash;60), mild disability (score: 61\u0026ndash;99), or full independence (score: 100).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIssues and challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChina\u0026apos;s traditional LTC system that heavily relies on families is eroding.\u0026nbsp;In the past ten years or more, the development of the LTC services policy of dementia in China, to some extent, has reflected both the attention and policy efforts by the government. Consequently, the challenges of the LTC system for\u0026nbsp;people with dementia have received growing attention in China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. No specificity and continuity in policy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndeed, to date, LTC services for people with dementia in China are included in the \u0026ldquo;fragmentation\u0026rdquo; policies with no specific guidance or an action plan. The fragmentation policies involve three aspects. The first is the fragmentation of government institutions. China currently yet has a national LTC management organization, resulting in departmental segmentation, affecting the actual implementation effect of policies (32). The second is the fragmentation of service institutions. Scientific and specific evaluation of the LTC access mechanism for people with dementia is lacking. There is no specific classification and management of care for dementia. Most care facilities and LTCI pilots regard dementia as a disability, mixing dementia patients with disabled older adults, and few detailed criteria differentiating the status of actual care needs for people with dementia. The third is the fragmentation of policy functions. Scientific standards and national norms of LTC-qualified personnel and professional educational programmers for people with dementia are inadequate. Shortage of scientific and valid information systems with oversight, management, and quality control, making it fail to estimate the level and quality of institutions and communities\u0026apos; LTC services for people with dementia. Overall, the untargeted and discontinuities in policy lead to the low availability of LTC services to people with dementia in China. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Professional workforce\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eshortage\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e \u003cstrong\u003eimproper allocation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn all countries with an aging population, the workforce needed to provide all types of LTC in a variety of settings is neither large enough nor adequately trained to meet the needs\u0026nbsp;(33).\u0026nbsp;The main workforce shortage is mental health professionals in China. First, the low number of dementia doctors in neurology, psychiatry, or geriatric departments and hospitals led to low diagnosis and treatment of dementia\u0026nbsp;(34). Second, China\u0026apos;s healthcare service resources are improperly allocated\u0026nbsp;(24), which is another reason why the diagnosis and management are still low and inadequate, especially in rural areas\u0026nbsp;(35).\u0026nbsp;Currently, the prevalence of dementia is substantially higher in rural areas than in urban\u0026nbsp;(7), and in northern China than in southern\u0026nbsp;(36). Instead, dementia sufferers in rural areas, especially those residing in northern areas, have not been diagnosed or received professional treatment and care due to limited affordable access to healthcare resources which has led to lower rates of diagnosis and treatment\u0026nbsp;(37), despite the dementia diagnosis rate in other urban areas is still less than 30%\u0026nbsp;(38).\u0026nbsp;Another workforce shortage is professional care workers. Professionals with professional knowledge of medicine, psychology, physiology, and sociology also have a huge gap. To alleviate the shortage of care workers, the Chinese government has made major modifications in relaxing the entry conditions, broadening the career development space, shortening the time for professional skill level promotion, and carrying out professional training\u0026nbsp;(39)Moreover, the governments of Guangdong Province, Jiangsu Province, and Shanghai adopted entry subsidy measures to enhance occupational attractiveness\u0026nbsp;(40). However, community-based care services are difficult to effectively meet the needs of people with dementia for professional care such as security and cognitive training\u0026nbsp;(41, 42). Similarly, China\u0026rsquo;s institutional care\u0026nbsp;is underserved in high-level care and overall support for people with dementia because of highly complex and differ in terms of organizational characteristics (e.g. proprietary status, size of unit), processes (access to specialized dementia care, case management, or palliative care), and structures of care (hours of care provided per resident, level of expertise, or diversity of workforce)\u0026nbsp;(43). Over 60 % of the care institutions had no professional nursing staff to meet the demand of LTC in rural China\u0026nbsp;(44). Thus, given the increasing need for dementia care in China, the inadequacy of professionals in dementia and dementia care services is the major barrier to improving the quality of care, leading to the LTC services being more difficult to come true.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Inconsistent design\u0026nbsp;in\u0026nbsp;financing source and\u003c/strong\u003e \u003cstrong\u003eeligibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe LTCI pilots and healthcare insurance may play a role in alleviating the social burden of dementia to some extent and improving the quality of life for people with dementia. However, the coverage of LTCI and basic medical insurance for dementia is too narrow (28, 32). Currently, only three cities, Guangzhou, Qingdao, and Shangrao, expand LTCI coverage to people with dementia. However, some organizations receive dementia benefits for very few people in these cities, for instance, a study suggested that 4582 obtained LTCI benefits in the pilot of Guangzhou, but only 791 (17.3%) people with dementia were covered (45). Moreover, \u0026nbsp;people with dementia have been included in the reimbursement scope of chronic disease management in local basic medical insurance outpatient clinics in some areas, which is only implemented in urban areas (28), so most people with dementia cannot be covered. Therefore, there are problems in the insured scope, fund pooling, eligibility rules, and supply standard, and lack of a unified evaluation system in the LTCI pilots and healthcare insurance, and dementia patients with the same health status in different regions are unable to gain the same services.\u003c/p\u003e"},{"header":"Discussion and recommendations ","content":"\u003cp\u003eThe continuous increase in China’s dementia population and the public LTC system that currently only benefits a relatively narrow and small group of\u0026nbsp;people with dementia, leaving many huge gaps of unmet needs. To address this situation, China’s strategy for the LTC system for dementia is developing; however, the strategy has yet to develop specific and continued policy. The deficiency of specificity and continuity in the policy of dementia is a major barrier to effective supervision and management of the allocation of mental health services and professional care workforce, and evaluation of the quality of care and integration of the services criteria. We hereby make policy recommendations in several high-priority areas, drawing on international experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Issuing a national strategic plan for stewardship, financing, and regulation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePolitically, adopting strategies to promote health and welfare for people with dementia is most powerful and essential at the national level.\u0026nbsp;The formal LTC for dementia has always been contained in healthcare services of national plans in many countries. For example, Italy and France have bespoke dementia evaluation units around the country, and UK has emphasized dementia as a national priority of health plans and recorded much success in increasing the diagnosis rate\u0026nbsp;(46)\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eAustria, Canada, and Japan have launched a national dementia strategy to address the scale, impact, and cost of dementia, to support its implementation, would ensure that people with dementia have access to services\u0026nbsp;(47-49).\u0026nbsp;Besides, three types of financing sources emerged when Japan, Germany, and South Korea instituted LTCI for dementia, which are tax revenues, social insurance, and copayments from individuals\u0026nbsp;(50). Similarly, both Germany and Japan assess care levels under specific guidelines\u0026nbsp;(50).\u003c/p\u003e\n\u003cp\u003eChina has yet issued a national strategic plan for dementia. The LTCI pilots and healthcare insurance fill a much-needed gap in public support for LTC of dementia in China. Yet, much work remains to be done. Currently, few beneficiaries due to strict eligibility criteria. Particularly, most participants of people with dementia are more often ineligible for benefits due to most of the pilots and healthcare insurance completely excluding the dementia population. A multifaceted strategy is recommended for strengthening the welfare of people with dementia in China. First, the government should confirm the issue of care for people with dementia in the first place and\u0026nbsp;the recognition of dementia as a public health priority, as seen in the cases of other countries.\u0026nbsp;More monitoring criteria must be created on the public agenda to meet the needs of people with dementia, particularly in rural areas.\u0026nbsp;Second, policymakers need to through tax revenues as a way to increase the financing and equity in the system\u0026nbsp;to improve people with dementia to access LTC and address the challenges of limited personal coverage, rural-urban disparities in access to LTC services, and uneven access to a certain support. Then, out-of-pocket payments should be utilized as an essential tool to curb moral hazard and prevent overutilization of services, as in the systems of Korea and Japan\u0026nbsp;(50). Third, the central government should provide grants to local governments to significantly increase the supply of LTC providers according to set targets, which are lessons learned from the Japanese LTCI system. Additionally, the implementation of assessing care levels under specific guidelines is crucial to people with dementia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Developing the professional workforce \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImproving the training and education of professionals working with people with dementia is a priority in the national plans of several countries. Strategies are emerging in some countries. Early diagnosis of dementia is the important first step for accessing services. Experts support that people with dementia can be identified using case-finding approaches that target individuals at high risk in community and primary care settings\u0026nbsp;(51). For example, Australia, Canada, the USA, and the UK have published guidelines for the diagnosis and management of dementia in primary care settings, such as employing Registered Nurses (RN), nurse practitioners (NP), and General Practitioners (GP) as dementia care experts in primary care settings, to encourage earlier detection and diagnosis\u0026nbsp;(46, 52-54). Furthermore, both Canada and the US emphasized that taking collaboration between health providers, professional organizations, and professional licensing bodies to develop a dementia care workforce\u0026nbsp;(47, 55). Thus, strategies are needed in China to increase the number of health professionals to deal with the influx of people with dementia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrimary healthcare is the first level of contact that individuals, families, and communities have with the healthcare system.\u0026nbsp;Unfortunately, the majority of China’s GP had low levels of recognition of roles for dementia care and believed that dementia care was within a specialist’s domain, not that of general practice\u0026nbsp;(52). Therefore, carrying out some national policies in China to train primary care professionals involved in making dementia diagnosis curial, such as the GP, who is often the first physician to observe patients with possible dementia\u0026nbsp;(56), and to overall improve the level of their services towards dementia care.\u0026nbsp;Additionally, owing to the disproportionate economic development in the coastal regions of China as compared with the inland regions, there is an equally uneven spatial distribution of social resources for LTC\u0026nbsp;(57). Thus, national dementia policies also need to consider how key contextual factors such as poverty, inequality, and limited resources, impact the health of the population and access to health services\u0026nbsp;(58). Furthermore, China’s government should introduce policies to develop an effective LTC professional care workforce regulatory framework and quality assurance system. On the demand side, strategies for improving knowledge and skills in dementia care is crucial for all care worker, especially for formal care. This improvement in care requires identifying the problems of the caregivers’ motivations, work conditions, and dementia education and training needs.\u0026nbsp;On the supply side, evidence-based practices of effective care are essential. Policymakers should leverage the available results of evidence-based practices and policy instruments, to execute a\u0026nbsp;scheme for adequate supply, distribution, and utilization of health providers. Meanwhile, using health providers working cooperation as a strategy to expand the capacity of the healthcare system in teams for meeting professional care and to respond to the growing needs of people with dementia is critical.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u003c/strong\u003e \u003cstrong\u003eDelivering person-centered care\u003c/strong\u003e \u003cstrong\u003eservices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerson-centered care is considered integral in providing high-quality care for people with dementia in several countries, such as Dementia Friendly Community (DFC) and Palliative Care (PC). DFC are proposed to empower and support people affected by dementia and their careers in society, understand their rights, and recognize their full potential\u0026nbsp;(59). DFC is critically important for those who wish to remain in their homes with our wide range of services including caregiver support and adult day care which are less costly than institutional care services. Consequently, DFC has been developed not only in Europe but also in Asian countries. For example, the UK is putting DFC on the policy agenda and becoming one of the first countries in the world committed to being a DFC\u0026nbsp;(60). Japan and the US also have established a strategy for creating DFC. Moreover, evidence suggests that covering Palliative Care\u0026nbsp;(PC)\u0026nbsp;for dementia is important. PC is broadly recognized as an essential model for providing effective, comprehensive, and transdisciplinary care for dementia\u0026nbsp;(61).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChina’s system of formal LTC for people with dementia is in the preliminary stage. Not only the availability of community-based health services related to dementia LTC in short supply, but most nursing institutions also find it difficult to provide LTC services for people with dementia\u0026nbsp;(26). Thus, China should establish a sound mental LTC services system and network, with specialized dementia health institutions as the main body, psychiatric units in general hospitals as auxiliary units, and community medical and health institutions for mental diseases as the foundation. The government should improve the community and institutional care services, and identify the need for sufficient training. On the one hand, policy and resource development to meet the demand for community and institutional dementia care services, is urgently needed, such as advancing the setup of DFC promoting PC as a policy agenda, and supporting essential resources. On the other hand, understanding how different care settings, such as nursing homes, bring their opportunities and challenges, including staff issues, workflow, and use policies, with dementia being a target of a nationwide program to reduce usage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Prospects for future research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the challenges posed by the increasing number of people with dementia, tackling the looming dementia crisis is simply insufficient. Based on this critical analysis, several warrant additional research we suggest. First, a better understanding of current LTC demand and supply is crucial to inform policy planning, resource allocation, and workforce reinforcing towards developing an effective and sustainable LTC that would meet the demands of the continuously increasing dementia population. Second, given the persistent urban-rural disparities in China, more research is needed to understand the gaps and inequalities in LTC needs and resources between people with dementia in urban and rural areas, to meet LTC needs for people with dementia all-around and narrow urban–rural divided. Third, as China progresses with the LTCI pilots and the combination of medical care and pension, it is essential to do rigorous independent evaluations before upscaling them.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWith China\u0026rsquo;s aging population and deteriorating health, a strong and accessible LTC system is vital to keep people with dementia well and out of the hospital. The looming dementia crisis has penetrated the consciousness of clinicians, researchers, policymakers, politicians, and the public at large. Overall, the vitality of the dementia service market has yet to be fully stimulated, problems such as unbalanced and inadequate development, insufficient effective supply, and low service quality still exist, and the LTC services needs for people with dementia have yet to be effectively met. The official policy, however, is still developing. Lessons from international experiences that are may able to help China conduct novel health policy, to offer a comprehensive set of services for people with dementia. It is urgent to establish a unified national LTC services system to promote the healthy development of care services for people with dementia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHC designed the study; HC and LL acquired, analyzed, interpreted of data; HC drafted the manuscript; HC,LL and XH revised manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Bureau of Statistics. https://data.stats.gov.cn/easyquery.htm?cn=C01\u0026amp;zb=A0303\u0026amp;sj=2022. Accessed 01 Mar 2023. .\u003c/li\u003e\n\u003cli\u003eGBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019;18(5):459-80.\u003c/li\u003e\n\u003cli\u003eElahi FM, Miller BL. A clinicopathological approach to the diagnosis of dementia. Nature reviews Neurology. 2017;13(8):457-76.\u003c/li\u003e\n\u003cli\u003eJutten RJ, Harrison JE, Lee Meeuw Kjoe PR, Ingala S, Vreeswijk R, van Deelen RAJ, et al. 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The Psychiatric clinics of North America. 2018;41(1):141-51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dementia, Long-term care, China, Policy system, Critical analysis","lastPublishedDoi":"10.21203/rs.3.rs-4263935/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4263935/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eChinese people with dementia account for approximately a quarter of the global burden of diseases, while the traditional long-term care system that heavily relies on families is eroding. In response, the Chinese Government has launched several policies for dementia.We aim to describe governance structure for long-term care, synthesizing the policy developments since 2010, and analyze current issues and challenges in the system, and provide policy recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod \u003c/strong\u003eA critical analysis was conducted by looking for government reports, news, and searching the PubMed, Web of Sciences and CNKI database on China’s long-term care system for dementia from 1 January 2010 to 30 August 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eWe described Chinese long-term care system for people with dementia from three overarching aspects: governance and policy, service delivery, and the system of financing. We found that the system is characterized by no specificity and continuity in policy, as well as lacking sections of professional long-term care services. Moreover, inconsistent designs in financing sources and eligibility have also been fully concerned.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eThis study demonstrated the vitality of the dementia service market has yet to be fully stimulated in the Chinese mainland, problems such as unbalanced and inadequate development, insufficient effective supply, and low service quality still exist, and the long-term care services needs for people with dementia have yet to be effectively met. Currently, China’s policy for people with dementia is developing. Lessons from international experiences are may able to help China conduct novel health policy. It’s urgent to establish a unified national services system to promote the healthy development of care services for people with dementia.\u003c/p\u003e","manuscriptTitle":"Long-term care system for people with dementia in China: A critical analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-22 09:34:39","doi":"10.21203/rs.3.rs-4263935/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"205573b5-eb78-4c38-a452-93b60ae56eb2","owner":[],"postedDate":"April 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-17T06:53:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-22 09:34:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4263935","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4263935","identity":"rs-4263935","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}