China has a large and growing elderly population, but to be old in China-particularly in the countryside-is to be vulnerable. In the country's rural areas there are few clinics and hospitals, and health insurance is virtually nonexistent. Compared with elderly Chinese living in urban areas, those in rural areas have a shorter life expectancy and a poorer quality of life.

Further, little academic research has focused on the health needs and health status of China's elderly. It is with the goal of addressing this deficit that Pengqian Fang, a trainee with CHP/PCOR's China-U.S. Health and Aging Research Fellowship, recently returned to China from Stanford. Fang is seeking to document the health disparities between China's rural and urban elderly population, and to use his findings to propose healthcare assistance programs for the elderly in rural areas of China.

Fang spent a year at Stanford studying health-services research concepts and methods and developing his research project.

In the project, which Fang refined with guidance from CHP/PCOR faculty, Fang will conduct a detailed survey of the health status, health needs, and healthcare utilization of elderly people in rural and urban areas of China, through in-home interviews in three Chinese provinces with different geographic and socioeconomic characteristics: Guizhou (in southwest China), Hubei (in central China), and Guangdong (in the southeast).

He will conduct the project in collaboration with the health departments of the

three provinces, and with support from Tongji Medical College in Wuhan, where he

is director and associate professor of healthcare management.

Fang's study will be among the first of its kind in China. Such research is needed, Fang explained, because China's elderly population (of whom 70 percent reside in rural areas) is growing steadily, and in the coming years its members will require medical services at increasing rates. According to the country's 2000 census, China has 132 million people over age 65, making up more than 10 percent of the population; the over-80 population, which numbers 10 million people, is increasing by 5.4 percent a year; and about 20 percent of all elderly people in the world live in China.

The elderly in China's rural areas face particular challenges in getting high-quality, affordable healthcare services, Fang explained. There are few clinics and hospitals in rural areas, and there is no government-sponsored health coverage for the elderly (like the United States' Medicare program) anywhere in China. All of these factors put China's rural elderly in a vulnerable position, especially those with disabilities or serious illnesses.

"This research will show the disparities that exist, and it will encourage a dialogue about policies to help rural elderly people in China," Fang said.

Fang plans to conduct his survey in the first half of 2005, analyze the data in the summer and fall, and return to Stanford in November 2005 to present the results. In each of the three provinces studied, the research team will recruit 500 households and will conduct interviews with all individuals age 65 and over who reside there, for an estimated final sample of 2,500 people.

The respondents will be asked for a variety of information, including their income and education, insurance status, health status, daily activities, social activity, mental health, utilization of healthcare services, and accessibility and affordability of medical care. The researchers will also interview community healthcare workers-including physicians, nurses, and administrative staff-to seek information on the health needs of the elderly and the barriers they and their healthcare providers face.

The China-U.S. Health and Aging Research Fellowship, administered jointly by

CHP/PCOR and the China Health Economics Institute (Beijing), aims to improve

healthcare quality and efficiency in China through an exchange program in which

selected Chinese health services researchers come to Stanford to study for six months to a year, and then return to China to conduct an original research project. The fellowship is funded by the National Institutes of Health's Fogarty International Center.

"I have learned very much from Stanford and this program," Fang said. "The classes I attended have given me very useful ideas." He noted that since health services research is still a young field in China-about ten years old-"we learn a lot from the United States, like how to ask the research question, how to get a grant, how to design a study."

One aspect of Stanford that particularly impressed Fang was its emphasis on interdisciplinary collaboration.

"This is a very good feature-the close relationship between different fields," he said. "In my country we are more focused on one narrow field."

Fang said he is interested in establishing research collaborations between Stanford and Tongji Medical College-an idea that he and CHP/PCOR's leadership will be exploring in the coming months.

There is much to admire about the U.S. healthcare system's emphasis on innovation and technology, Fang said. Still, he said, "I don't hope for China to follow the U.S. health system," with its heavy reliance on free-market principles. For one thing, "medicine here is very costly." He cited a personal example of how he fractured his arm in a minor bicycle accident, and how his emergency room visit for the injury, along with a follow-up physician appointment, cost more than $1,000. "I was surprised it cost so much," he said.

A review of the fellowship program conducted by officials at the China Health Economics Institute last fall concluded that it has been successful and valuable. Leaders at the institute said the trainees' Stanford experience has enhanced their intellectual abilities, their knowledge of research methodology, their leadership capacity, and their ability to collaborate internationally.