[Note: below is Chapter 6 from Great Wall of Numbers]
In October 2011 I had a bad bout with food and ended up having to stay in a hospital for a few weeks in provincial China. In contrast to the modern facilities at Huadong hospital in Shanghai (which I have also visited), all three public hospitals in Bengbu, Anhui were at the time, less than sanitary and for residents of the West, a seemingly step-backwards-in-time. During my stay, I befriended one of the surgeons who had studied in Switzerland. Dr. Wang or “Charley” as he affectionately called himself, gave me a tour of the in-patient facilities I was staying and said, “Tim, look around, we can barely cope with medicating and treating these patients – how could we possibly take over the world as some media outlets suggest?”
He raises a visceral point. Despite the abundant growth over the past three decades, one of the industries that has had its share of growing pains is the health care sector (see Chapter 19 for more). While the debate over government versus private ownership and maintenance of the industry continues on in China, there are a number of opportunities that US medical companies can capitalize on. For example, while the pharmaceutical industry is basically tied up with patent and legal proceeding and negotiations on both sides of the Pacific, US-based medical equipment and medical device manufacturers now have a liberalized export channel compared to just a few years ago.
Overlooked yet increasingly important
On a national level, life expectancy in China has grown from 65 in 1976 to 73 in 2010. While its increase may have plateaued, reaching farther back in time illustrates how prolonged life expectancy is a positive spillover effect due to economic growth. For instance, according to Xinhua, the average life expectancy in Guangdong (the wealthiest province) has risen from 31 in 1949 to 75 in 2008.
Assuming the retirement age is not increased, by 2050, it is estimated that 31% of China’s population will be near the age of retirement. In contrast, today about 14.8% of China’s population is over the age of 60.
Yet with these demographic changes come different opportunities as well. According to Zhao Baohua of the Gerontological Society of China, he notes that in terms of entertainment and “toys” for the elderly, “[a]bout 99 percent of Chinese toy factories just produce items for children, but in more-developed economies about 40 percent of toys are designed for older people. It may take China 30 years to catch up with some countries in this area.”
Here is an area where Western-based toy, games and entertainment companies can export goods and services to a market ripe with potential. For instance, Amazon.com has several pages of “toys for the elderly” and “toys and games for senior citizens.” And as described below, there are a number of other made-for-the-elderly products that are currently available in the West but not in China.
This also raises the question, what activities do elderly populations in other countries have access to? One potential answer to that could be the apartment complex where I currently live in Changning, Shanghai which has a small playground that is typically used by both toddlers and the elderly alike. According to a Reuters report, “there were over 15,000 pieces of elderly workout equipment parks across Japan.” This same report noted that “an elderly playground starts at 8 million yen ($87,220), including the installation of equipment and instructors’ fees.” Thus there is a potential business opportunity for US firms that develop playgrounds to export their products and services to China.
What about demobilizing conditions? In the Netherlands, a village was recently built that “doubles as a nursing home,” serving clients suffering from dementia and Alzheimer’s. Similarly in Switzerland, a $26 million village has been built catering to the elderly afflicted with Alzheimer’s as well. In 2007, six million Chinese suffered from Alzheimer’s and that number is expected to grow markedly as the population ages. In fact, one third of all Alzheimer’s sufferers live in China. Shanghai alone has 120,000 residents with Alzheimer’s or dementia. While the debate and conversation over how to help treat these patients is still on-going, many Chinese families have now found solace through new treatment centers opening across the country. And with new centers comes potential markets.
What can foreigner medical experts do on the mainland?
In November 2012 I spoke with J.J. Liu who is originally from Beijing. After completing graduate school he moved to California and worked in the bio-med industry for about 20 years before returning and now is the marketing manager for QIAGEN’s operations in China. QIAGEN is a German biotech firm that builds and designs technologies to diagnose and measure biological specimens (e.g., when you give a blood test, they make the machine that analyses it). Liu mentioned that as China ages the potential to provide services for the elderly increases as well. For example, he noted that because of the economic boom in the 1990s and early 2000s many of the elderly now have more assets and funds to spend on improving their health, including the possibility of residing in assisted living facilities – or as he observed, “villas and hotel-style living that are arguably more culturally acceptable.”
Historically, Liu explains, “in the past the average resident did not have the resources to receive medical treatment – while the medical knowledge and facilities were lacking – families simply did not have the assets and resources to finance medical treatments.” As a consequence, many families simply self-medicated through the purchase and consumption of relatively cheap drugs and TCM (Traditional Chinese Medicine or 中医) at local pharmacies. While this self-medication phenomenon still takes place, Liu and others expect that these consumers will be able to utilize modernized Class 3 hospital facilities (the top flight), many of which are now stocked with the latest medical equipment.
What other opportunities can foreign companies become involved in?
In Chapter 3 I noted that Chinese consumers largely perceive foreign brands as premium quality. Liu noted that pharmaceutical brands are no different, as “Chinese patients are partial to imported products.” Yet one of the limiting factors has been relatively high prices. And some medicines like insulin for diabetes have few generic substitutes. This price inelasticity means that the 92.3 million diabetes sufferers alone (China is now the “capital of diabetes”) have created an additional $3.2 billion drug market.
Liu also expects that the current health care reforms being implemented by various levels of government via the 12th Five-year Plan will have “wide-ranging effects, most notably in terms of pharmaceutical costs. Previously multinational companies [MNCs] were given a preferential pricing policy that allowed them to charge 100-200% markups on medicines whose patents were already running out in the West. In the next several years this markup will be reduced to a mere 10-20% while simultaneously generic brands are introduced.”
Prior to these reforms, Chinese policies required that in order for MNCs to have access to the market they would need to produce and manufacture the pharmaceuticals on the mainland. In doing this, policy makers expected a knowledge transfer would take place – as in the auto industry, which I briefly discuss later in Chapter 10 – as MNCs would need to train local staff and administrators.
Subsequently, while very little original research and development has taken place on the mainland over the past decade, going forward many MNC pharmaceuticals have opened up regional headquarters in China to take advantage of both the increased resources being placed into the health care industry as well as recruiting from a well-trained local talent pool.
What does this mean for you and your company?
In six years since it was established, QIAGEN’s Asia Pacific sales have grown from zero to accounting for almost 20% of global sales. Simultaneously its Shanghai headquarters has grown from 1 employee to 400. How has it done this? Its double digit growth rates comes from selling medical systems – like those described above – through distributor channels to hospitals and clinical research facilities (QIAGEN as a whole generated $1.17 billion in 2011). And because of the various reforms being enacted in all cities, counties and provinces, there are substantial areas of growth for medical providers, both domestic and foreign. One other area where Liu sees specific potential opportunities for foreign experts is to help set up and train staff at a wide-array of facilities, including retirement villas. Thus if you and your company already provide health care services you may be able to find new opportunities and revenue streams in China as well.
Lack of products presents opportunities
While services such as LifeCall’s medical alarm (creators of the catchphrase: “Help, I have fallen and I can’t get up”) have been offered to US residents for more than 15 years, there are few equivalents in China at this time. Even though it is debatable whether or not such a service would prove to be popular in China, one possible product that has gone under the radar and could appeal to elderly Chinese consumers are e-Pants, designed by engineers at Virginia Tech. Embedded in the pants are several electronic gyroscopes and accelerometers that communicate to nearby computers via Bluetooth and can detect whether or not a wearer has fallen down. Similarly a team of researchers at the University of Adelaide are using RFIDs and software to detect sensory movement and help monitor the activities of the elderly so that these aged consumers can continue to live both independently and safely at home (e.g., alert emergency providers if an accident occurs). Maybe you or your company can integrate LifeCall’s functionality with e-Pants. Or perhaps your firm can take a page from Fujitsu who in February 2013 unveiled a “smart” cane called the Stylistic S01. Embedded in the handle of the cane is a GPS with LED lights that can help point the user in the correct direction. In addition, built-in sensors can monitor temperature, heart rate and even humidity. Their target market is the elderly as well.
Because of Japan’s rapidly aging population (it has the highest average age in the world) its engineers are also at the forefront of innovating and producing both machines and robotic solutions to provide support for the elderly. For example, the AGNES suit allows its wearers to feel what it is like to have limitations in physical motility. The Hybrid assistive limb (HAL) is a new robotic exoskeleton developed by Tsukuba University in a bid to help improve the physical capabilities of its users. In the UK there is Hector, a mobile “assistive” robot that can follow its owners and take commands via a touchscreen. In the US, there are a number of social and domestic cleaning robotic projects such as the PR2 from Willow Garage and the Roomba from iRobot. And since China is rapidly aging as well, this presents an opportunity not just for foreign robotics companies but also IT firms to export their solutions to China (see Chapter 13 as well).
Digital demographic differences
While personal computer ownership in China continues to increase over the past two decades, as the average urban salary is about $3,430 a year, the typical urbanite usually does not have the funds to pay for one at home. That serves as a reason why, internet bars or net cafes (wangba) are substantially much more popular than their Western equivalent. Xinhua estimates that as of 2009 there are more than 138,000 “cybercafés” in China. And 70% of the customers are between the ages of 18 and 30.
So where does this leave the aged and elderly?
As I mention later in Chapter 13, both the iOS and Android app marketplace’s in the US have a number of simple games that some older audiences have gravitated towards. And as smartphone proliferation continues in China, this presents Western developers and programmers with an opportunity to port and translate their games to a similar demographic across the Pacific.
For example, in 2012 approximately 189 smartphones were sold in China and at the end of November 2012 there were now 1.104 billion phone users on the mainland – 233.4 million were 3G users (3G adoption will increase by 100 million in 2013). This past summer China overtook the US to become the largest smartphone market. Flurry now estimates that as of February 2013 there were 246 million smart devices in China compared with 230 million in the US. It is thus unsurprising that China is also the fastest growing market for iOS and Android devices. Yet in terms of demographics, the vast majority (~90%) of smartphones on the mainland are owned by users who are less than 55 years old.
As I mention later in Chapter 13, in the US, 50% of Solitaire and FreeCell players are senior citizens and 44% of US seniors have played solo games online. Yet a 2012 Flurry Analytics report found that only a mere 3% of US users aged 55 or older, play games on their phones. However, in terms of total tablet and smartphone ownership, according to Flurry, in the US this same elderly demographic group (55+) represents 17% of the total tablet and smartphone ownership.
While open market research is relatively scarce on the Chinese side, CNNIC (which is part of the Ministry of Information Industry) estimates that the internet penetration rate for those over 50 is the lowest, at 7% in 2010. A 2010 IDC report found only 7.1% of those aged 55 or older play computer games in China. One estimate from iiMedia was that 10.1% of Android users in 2011 were aged 45 and older. iResearch estimates that 3.8% of iPhone users in 2011 were 45 and older. Similarly, a February 2012 report also from iResearch found that approximately 6% of Chinese mobile internet users were 45 and older. And Askci estimates that only 1.5% of 50+ year olds in China had a smartphone by the end of 2011. So in short, smartphone and computer penetration is relatively subdued within older demographic brackets.
Why is there such a disparity between the US and China? Why does it matter?
I posed this question to a number of Chinese students and colleagues and they noted that the vast majority of the elderly in China were born and raised on farms and are unfamiliar with the latest technology (e.g., only 51.3% of the population is currently urbanized). Another issue could be illiteracy rates. For example, an older New York Times report noted that many of the less developed more rural regions of China have much higher illiteracy rates. In 2001, parts of Tibet had up to 42% illiteracy rates. Yet trends could be changing as We Are Social estimates that there are at least five million shoppers and increasing over the age of 50 in China.
Apps that cater to the elderly
One argument against investing resources towards this demographic group is that you do not, with such relatively low market penetration why invest the resources for a risky return on capital? However one unseen opportunity is the ‘long tail’ – that the simplified game you make could find an audience with other demographic groups such as primary school students at the other end of the population pyramid.
For example, Brain Age is a best-selling Japanese puzzle game for the Nintendo DS (a handheld gaming console) that is popular and successful in part due to its simplicity and ease of use for a wide-range of ages. Perhaps Western developers could look to the simplified user experience design (UXD) in Brain Age as they port their games over to Chinese markets.
In my own anecdotal experience I think an overlooked, yet important phenomenon regarding elderly Chinese is that they are incredibly social and often even physically active. On any given night you will see large groups of seniors dancing in plazas, practicing qigong and playing mahjong along the roads. As my students noted above and the CNNIC data illustrated, if a developer could make accessing apps and the internet itself relatively easier elderly customers may find smartphones less imposing and confusing (e.g., tap on a big simple picture of the person you want to talk to).
And in addition to using easy-to-see objects, be sure to modify the games to include Chinese traditions, symbols and cultural tie-ins – or in other words ‘Western video games with Chinese characteristics.’ For example: the color red, number 8, and the Chinese knot (Zhōngguó jié) are all considered lucky. In the early 2000s a knock-off of Red Bull completely redesigned their can to fit the Chinese penchant for red and gold. Perhaps creatively integrating these symbols into your game would prove crowd-pleasing.
Also, even though gambling is currently banned on the mainland, this has not prevented small-scale gambling activities from taking place (e.g., in 2007 Macau overtook Las Vegas in gambling revenue). From my observations, a large part of gambling is done in person on pieces of cardboard in the streets or in little game houses (e.g., tea houses and mahjong parlors). This is not an endorsement of these illicit activities. Rather this consumer behavior presents an opportunity for app developers to focus on both simplicity and the social aspect of any app that is created. And since gambling is popular across many demographic groups, perhaps designing a “social” fortune-style game or a non-monetary betting app would find success across the mainland.
Thus while there is viable market potential for game and entertainment developers to create applications for both sides of the Pacific, careful due diligence of age and technology distribution and proliferation is recommended.
Service with a smile
Another possible area for business opportunities is senior care services. In a December 2012 email exchange with Qian Jianchu, a professor at Shanghai Institute of Foreign Trade, he mentioned to me that “elderly nursing will be the most prosperous industry in China in the next 10-50 years. The market is currently at a relatively low penetration level at present due to the lack of management experiences and promotion. Therefore foreign firms with experience may find many opportunities in this segment.” Why is this the case? Because as noted above, assuming the retirement age is not increased, by 2050 it is estimated that 31% of China’s population will be of retirement age; and within 40 years China “will have nearly 500 million elderly people.” Yet despite this increasingly larger demographic bracket, “only 8% of elderly Chinese consumers feel that marketers adequately target them with advertising and products.”
There are exceptions such as the US-based hedge fund Fortress Investment Group who is investing in and working with China Senior Care to provide “elderly care and retirement facilities.”
And while assisted living and senior living centers have become increasingly popular in Western countries, aside from several token centers in China, they are virtually non-existent. That is to say, only 1.6% of people over 60 on the mainland (compared with 8% in developed countries) are accommodated in some way by care facilities. Or rather, all but a few of the affluent do not currently receive services from an assisted living center. Yet according to a report from China’s National Committee on Ageing, about 12 million Chinese over the age of 60 would consider retirement villages an option. This potential is one of the reasons why J.J. Liu recommended the market segment for potential entry by experienced foreign firms. In fact, Fortress is investing $1 billion over the next several years to build and operate centers in larger cities like Shanghai and Beijing. And the sky may be the limit, as the most expensive 7-star nursing home in Hainan province targeted and tailored at seniors recently opened in Haikou, charging between $1,283 to $2,444 per month.
In contrast, a 2008 study noted that approximately 1.4 million Americans currently live in several thousand assisted living centers and nursing homes. Thus the potential opportunities in China to not only train the staff but also to sell and equip the centers with vital materials provide Western firms and entrepreneurs with new revenue streams in the immediate future.
Some critics may argue that firms like Fortress Capital are getting ahead of themselves, that there may be very little genuine demand – regardless of costs – for assisted living. For example, Shanghai International Medical Zone (SIMZ) had a tough time starting up several years ago. It was initially planned to be a luxury retirement village targeting wealthier retirees. However as part of its marketing push its owners “boasted an investment partnership with Augustinum Group, a leading provider of retirement homes in Germany.” Yet work on SIMZ actually stalled for a few years and Augustinum said it never made investments on the mainland. SIMZ has since been completed and subsequently foreign firms such as Eli Lily (a large US-based pharmaceutical company) and Parkway (a Singapore-based health care provider) have begun operating in the zone. Thus even though there is potential due to an expanding market driven by a rise in living standards, investors should still be cautious. Another argument notes that one of the three Confucian ideals that children are taught is filial piety (xiào): take care of their parents when they grow older. Yet because of cultural dynamics, home healthcare may eventually become an accepted alternative as Liu noted above. Just as generational changes in the West led to outsourcing care of our aged parents, so too may the post-1980s generations (bālínghòu) do in China.
I also spoke with Adam Clemans who echoed similar rationales and prospects. Clemans is an American pharmacist who works at an international hospital in Shanghai. According to him, “while somewhat tangential with the filial piety idea, many Chinese children do not necessarily want to (or cannot afford to) spend enormous amounts of money on their parents, but rather they want to get them things that seem like they might be expensive. The simple fact that something is imported or made by a foreign company makes it seem valuable and special. For example, relatively mundane “low-tech” items like slip-proof rugs or handle bars for getting on and off the toilet could be attainable hits. In addition, I think there might be a third market (upper-middle class) for elderly care as well. Not necessarily super-luxury, but with more Western characteristics (like clean floors & privacy). Right now it seems like there seems to only be two options, cheap or extremely expensive.”
With a middle class currently numbering 300 million – and estimated to grow to 600 million by 2020 – these alternative care options could become increasingly possible for consumer and suppliers alike. Yet again it should be pointed out that middle class is defined as those with at least $3,000 a year in disposable income (e.g., earn between $10,000 and 60,000 pre-tax). So while they have more funds for supporting their elderly relatives, they may not have enough to buy a product like a walk-in bathtub quite yet. In addition, your company may be able to cater to clients from the Greater China region such as elderly Hong Kong pensioners. According to the Guangdong provincial government, 69,000 elderly Hong Kong pensioners now live in retirement homes throughout the Pearl River Delta – the bulk of which (more than 10,000) reside in Guangzhou. One of the main reasons is that the quality of care is purportedly the same as it is in Hong Kong yet the labor costs are significantly lower thus enabling retirees to live more flexible in terms of finances.
Takeaway: The rapid demographic changes within China present health care providers, robotic manufacturers and game developers with opportunities. What products and services can you and your company invent and export to China? These solutions can range from the seemingly obvious, personal movers like the Rascal to something less evident such as old-age proofing doors and cabinets or even simple smartphone games.