Improving Elderly Care: A Comparative Analysis of Germany and China

Demographic shifts due to aging populations present significant challenges for societies worldwide. Countries like China and Germany are experiencing rapid population aging, leading to substantial difficulties in providing adequate eldercare in the coming decades. In addition, this increasing demand for eldercare services not only highlights existing challenges in gender inequality, but also exacerbates them. Most formal and informal eldercare work is still provided by women. However, rising female employment has in part intensified caregiver shortages, and particularly affected the traditional care division within families. Working women often face a "double burden" of paid work and unpaid caregiving responsibilities at home. Many resort to part-time, precarious, low-paid jobs to balance these demands, resulting in long-term financial insecurity. At the same time, the majority of professional care workers are also women, facing less-than-ideal working conditions with long working hours, and low remuneration.  

Overall, there is a clear disconnect between the ideals of "good care" and the realities in both paid and unpaid care work, with caregivers often facing exploitation and neglect.

To address these challenges, the Friedrich-Ebert-Foundation (FES) Shanghai and the Ginling College of Nanjing Normal University (NNU; 南京师范大学金陵女子学院) organized an exchange of academic and professional experts from China and Germany. The goal was to analyze the differences and similarities in the respective eldercare systems and to identify potential solutions. Throughout 2022 and 2023, NNU and FES Shanghai facilitated multiple roundtable discussions and a hybrid conference in Nanjing, exploring topics such as the revaluation of professional care work, the impact of migration and structural gender imbalances on professional care workers, and the potential for local model projects to be scaled nationally.

This initiative aimed to provide a comprehensive analysis of the eldercare systems in both China and Germany, examining current challenges and feasible approaches to address them. Despite their distinct cultural, political, economic, and historical contexts, both countries face common issues related to eldercare.

Contextual Differences and Shared Challenges

As part of this project, two experts were invited to create country dossiers that highlight the distinctive societal contexts and mutual challenges of eldercare in China and Germany.

Prof. Hildegard THEOBALD, an expert in organizational gerontology at the University of Vechta, focuses her dossier on the challenges in Germany since the 1990s. She discusses the introduction of universal long-term care insurance in 1995, which redefined social benefits and significantly impacted family support and professional infrastructure. By examining the diverse eldercare needs that vary between rural and urban areas, as well as between East and West Germany, Prof. Theobald analyzes different care practices and models. Her work considers factors such as gender, socioeconomic status, and migration, drawing on societal changes and the roles of civil society actors to inform effective policy approaches.

In contrast, Prof. JIN Yihong (金一虹), a professor at the Ginling College of NNU and director of the Academic Committee of the Women’s and Gender Studies Research Center, examines the challenges of China’s eldercare system as the country transitions into an aging society. Her dossier highlights the acceleration of the aging population amid declining birth rates and the uneven distribution of elderly individuals between urban and rural areas. This disparity particularly complicates care provision in rural regions. Prof. Jin also discusses the importance of rural-urban migration, and informal caregivers in China, as well as the recent evolution of the eldercare model. Key issues include the persistent shortage of professional eldercare workers, driven by unfavorable working conditions and a lack of labor protections. She emphasizes the need for enhanced institutional support for caregivers, a revaluation of professional care work, and more opportunities for career advancement.

1. Demographic Challenges in Germany and China

Both authors begin by exploring the demographic shifts and the challenges these pose to eldercare systems in Germany and China. Prof. Jin notes that since the turn of the century, China has seen a substantial increase in its elderly demographic, with the proportion of individuals aged 65 and older more than doubling to approximately 15% between 2000 and 2022. Similarly, Prof. Theobald highlights that in Germany, this demographic will increase from 15% in 1990 to an estimated 27% by 2035, with those over 80 making up 7% of the population in 2020.

While the relative proportion of elderly individuals in China remains lower than in Germany, the absolute number—over 200 million seniors, the highest in the world—illustrates that eldercare will be a central challenge for China in the coming decades. Moreover, China's aging rate has surpassed that of Japan, prompting the Chinese National Health Commission to warn that rapid population aging, coupled with low birth rates, is likely to become the norm.

In their dossiers, both authors delineate different cohorts that make up the elderly populations of their respective countries. Professor Jin particularly highlights the different aging trends in urban centers and rural communities in China. Although both regions are seeing an increase in elderly populations, the aging rate is more pronounced in the countryside. This disparity is concerning, as rural areas typically have lower income levels, fewer social welfare resources, and limited medical care options compared to urban centers.

German urban centers are also exhibiting lower rates of aging compared to rural areas. However, Prof. Theobald emphasizes the importance of considering regional differences, as development varies drastically between eastern and western German states. The highest proportions of elderly individuals reside in eastern states, which continue to experience a more rapid increase in the elderly population compared to their western counterparts. City states on the other hand have the most favourable demographics.

As life expectancy increases, a direct impact on the number of people requiring care can be well observed in both countries. In Germany, the number of care recipients has risen from 1.6 million in 1996 to 3.8 million in 2019, with projections suggesting it could reach around 6 million by 2030.

    1.1 Economic Implications of Aging Populations

Both authors express that the increase in the elderly population leads to heightened demand for care services and a loss of labor resources, which subsequently impacts local economies, welfare states, and care systems. Prof. Jin writes, that in China this concern is often summarized by the idiom “getting old before getting rich.” In both countries, the trend of decreasing labor force participation and a lack of care services is particularly observable in rural areas. Prof. Jin attributes this to rural labor migration to cities. Many middle-aged and elderly women from rural areas, crucial for traditional family-based eldercare, are increasingly choosing to work in urban centers, particularly in the local care industry.

In Germany, Prof. Theobald highlights the importance of financial contributions of the labor force to the welfare system. While the increase in working women has temporarily stabilized these contributions, similar to the situation in China, women's integration into the labor market has led to a shift in familial care structures and added additional burden to unpaid caregivers.

2. Care Economy, Social Welfare Insurance, and Family Care Models

    2.1 China's Model of Family Caregivers

Prof. Jin warns that more pressing than the concern about “getting old before getting rich” is that China may be on track to be “getting old before being prepared [to care for its aging population],” as the rapid increase in the 80+ demographic poses further challenges. An increase in this cohort would lead to a rise in long-term care recipients with disabilities and a heightened demand for specialized nursing staff. The central government has recognized the urgency of developing adequate and sustainable eldercare responses and has declared this a national strategic priority. Numerous policies and regulations have been introduced on national and local level since 1994, including the 2019 "National Medium- and Long-Term Plan for Actively Responding to Population Aging" (国家积极应对人口老龄化中长期规划).

Despite these efforts, the number of nursing homes and beds remains far below international standards. At the same time, government initiatives have been unable to close qualitative gaps and prevent contradictions between high demand for affordable public facilities and low occupancy in high-end care homes. Although the supply of elderly care workers has increased, it still lags behind growing demand, with estimates of shortages ranging from millions to tens of millions. Currently, there are about 500,000 nursing professionals in elder care homes in China, with only 195,600 being professional caregivers, emphasizing the critical shortage. At the same time, the sector struggles with high turnover rates, ranging from 30% to 60%, and there is a limited influx of new talent, with only 6,000 students nationwide studying elderly care. One defining cause for this shortage and high turnover rates among care workers is the challenging working conditions, characterized by high labor intensity, long hours, and low pay. Many caregivers earn salaries at or near the minimum wage and often lack social insurance. As a result, occupational burnout and mental health problems are prevalent in the sector.

The reform and development of China's elder care service system is primarily driven by government initiatives. Since 2012, the emphasis of these initiatives has shifted from institutional care to community and family-based care trying to counter the challenges posed by a lack of professional care workers. Prof. Jin highlights the "90-7-3" model, which aims for 90% of seniors to remain at home with family support, 7% to access community services, and 3% to use institutional care. While this model aligns with traditional Chinese family values and is viewed as an efficient solution to growing elder care demand by policymakers, it faces limitations. Under this model, family caregivers — often elderly women — bear the brunt of responsibility for caring for disabled seniors. Additionally, the shrinking size of Chinese families has further weakened families' ability to provide support. As the "4-2-1" family structure (four grandparents, two parents, one child) becomes more common, the reliance on family-based care is becoming increasingly unsustainable, leading to a rising demand for outsourced elderly care services.

    2.2 Germany's Long-Term Care Insurance and Reforms

In Germany, the landscape of eldercare has evolved significantly since the introduction of long-term care insurance in 1995. Prof. Theobald outlines how this insurance has expanded both outpatient and inpatient services, with the number of users increasing to 1.8 million by 2019. In light of the rapidly aging society in Germany, it is estimated that by 2030, an additional 140,000 caregivers will be needed to meet the demand. However, the challenges faced by the sector parallel those in China, with low attractiveness of training programs discouraging recruitment and retention of talent.

While some stakeholders advocate for increased state responsibility, others prefer a mix of state support, volunteerism, and family involvement in care. Prof. Theobald notes that the lack of adequate remuneration and the burdensome working conditions deter potential recruits, creating a significant challenge in securing a sufficient workforce. Some reforms have been proposed to tackle these long-standing discrepancies, among them Prof. Theobald mentions the introduction of a nationwide tariff agreement to standardize widely disparaging wages of care professionals. However, this agreement has been criticized by some stakeholders as insufficient and a subsequent bill aiming to improve healthcare provisions has been challenged in front of courts by private-sector care providers.

Furthermore, she argues that the low attractiveness of training programs for nursing professionals, partially due to inadequate remuneration, discourages successful recruitment and retainment of talent, creating a significant challenge in securing a sufficient workforce. Furthermore, there are considerable barriers for caregiver assistants who wish to advance their qualifications to become professional caregivers. Nevertheless, there have been political initiatives aiming to improve working and training conditions and to raise the number of trainees. In fact, Germany has seen an increase in nursing apprentices of about 30% between 2011 and 2019. Prof. Theobald highlights how the increased training wages and the elimination of training fees, as well as new opportunities for further specialization, particularly for existing caregivers, have contributed to this growth.

In addition to institutional caregiving, Prof. Theobald also addresses the rise of other care work models. The concept of “care mix” for example is a combination of family care and professional services. Related efforts aim to increase the use of home-based care services and the employment of household workers. One particularly common type of this care is "24-hour care" arrangements within private households. This type of care typically involves a live-in caregiver, who is often sourced through the grey market or various agencies and has a migrant background. Such arrangements are frequently marked by irregular and high-stress working conditions.

Additionally, Prof. Theobald touches on the precarious conditions of live-in care workers in these scenarios. However, the costs of both at-home care and accommodation in elderly care homes have become increasingly difficult to shoulder for most families. Therefore, there have been increasing calls for better financial resources and municipal funding for care infrastructure, to alleviate pressure from families, and securing the employability of primary familial caregivers.

    2.3 Gender Inequalities in Care Work

A recurring theme in both dossiers is the gender dimension of caregiving. Gender inequality in elderly care work is a pressing issue that reflects broader societal disparities. In both China and Germany, paid and unpaid care work is predominantly provided by women. In China, 80% to 90% of caregivers are female. Prof. Jin highlights that women, often with limited job options, dominate elder care roles in China. Especially rural migrants and recently unemployed urban residents, particularly those supporting families, face financial pressures. In addition, Prof. Jin emphasizes that the perception of a profession, such as elder care work, as “women’s work,” reinforces stereotypes and contributes to low wages and professional value. At the same time, the dominance of women in the field of elder care and care work in general solidifies the gender stereotype that nursing work is women’s work. The profession is often perceived to be low-skilled, and care workers are seen as lacking education. High turnover rates in the sector and the decentralized nature of the profession, result in low organization among care workers, limiting their bargaining power and awareness of rights.

Interestingly, among the care professions, elder care is valued the least compared to other types like child care. According to Prof. Jin, this is a result of perspectives that view elder care as a consumption rather than an investment in the future like child care. To increase the value of elder care and other care work, Prof. Jin calls for addressing gender discrimination in care professions. While societal stereotypes about women being specially equipped for caring are at the base of the large gender gap in care work, Prof. Jin also emphasizes the economic factors that reinforce the imbalance between men and women in the sector. According to her, men have more job options and are less likely to take up care jobs due to a disparity between labor input and remuneration. However, Prof. Jin mentions that research suggests that men could in fact have certain advantages in care jobs, as they commonly require physical strength, particularly when caring for disabled elderly.

In Germany, Prof. Theobald observes a similar trend where women traditionally handle elder care. However, since the late 1990s, there has been a shift towards shared caregiving responsibilities, supported by a “welfare mix” system. Unpaid care hours have decreased, partly due to better integration of ambulatory services, enabling improved work-life balance for caregivers. This trend has also allowed better parity of care work distribution between household partners.

Despite this progress, women still face challenges in balancing careers and unpaid caregiving. In the formal sector, on the other hand, women also made up 84% of the workforce in 2019, often under challenging conditions, including low staffing levels, time pressure, and physical and mental strain. On top of that, the sector offers limited professional development opportunities and approximately 70% of caregivers work part-time, which results in limited social security benefits and further deters new talent in caregiving roles, mirroring issues seen in China.

3. Innovative Care Models: Learning from Each Other

Both countries are exploring innovative care models to address the challenges of eldercare.

China is actively developing its elder care sector and insurance system, piloting long-term care insurance policies in several cities. In Shanghai, this initiative has contributed to higher salaries and performance pay for employees of different elder care services, attracting younger talent to the industry and raising staff retention rates. Drawing on international models from Germany, Japan, and Australia, the central government aims to establish a national elder care service insurance system, though progress remains slow and faces significant challenges.

For Germany, Prof. Theobald presents selected innovative elder care projects focusing on integration and community work. One of them is the “Care for Integration” program. Through the program, refugees are trained as elder care assistants, with 80% completing the program as elderly care assistants, many of whom expressed interest in pursuing further qualifications. This initiative also aimed to improve gender balance in the care workforce, with strong male participation. Another project, “Gute Arbeitsbedingungen in der Pflege” (Good Working Conditions in Care) ran between 2019 and 2023. The program aimed to improve work environments in care facilities by enhancing organization, leadership skills, and work hours, thereby strengthening employee commitment. While its short pilot phase posed limitations, the project laid the groundwork for a federal rollout through regional centers. Among the projects focusing on community engagement, Prof. Theobald explores one fostering more dementia-friendly communities, and introduces the overarching concept of “Caring Communities”. Subsequent initiatives, address the growing need for local care structures, by focusing on community involvement and integrating neighbors and volunteers with professionals to create a supportive care culture. According to Prof. Theobald, recent studies suggest around 1,000 such projects have emerged in various communities.

4. Conclusion: Toward Sustainable Solutions

In conclusion, the dossiers by Prof. Theobald and Prof. Jin exemplify the challenges posed by an aging population in both China and Germany. While the underlying issues are similar, the solutions are influenced by unique cultural, political, and economic factors in each country. Notably, the distinction between formal and informal elderly care is pronounced; in China, political initiatives actively promote informal and formal caregiving, whereas, in Germany, discussions and policies often focus on enhancing formal care services. Furthermore, each dossier addresses country-specific policies, such as challenges and opportunities arising from the migration background of caregivers or caretakers. Understanding the challenges faced in different contexts allows for deeper insights into effective long-term solutions.

Despite their differences, it is evident that caregiving remains predominantly a female responsibility, making gender equality a central aspect of care work. All in all this not only burdens female care workers but also substantially sabotages the elderly care system as a whole. Addressing the challenges faced by female caregivers is essential not only for enhancing the quality of care but also for promoting gender equality within the workforce. As both China and Germany navigate the complexities of elderly care, a comprehensive approach that considers the specific needs of the elderly population, the working conditions of caregivers, and the gender dynamics inherent in caregiving is crucial for success. The dossiers by Prof. Theobald and Jin identify key areas for policy intervention, emphasizing the importance of improving working conditions, increasing support for caregivers, and addressing barriers that hinder the development of sustainable elderly care.

You can download the dossiers of Prof. Hildegard Theobald (in German) and Prof. Jin Yihong (in Chinese) here.