Mainstreaming Aging in China: Ensuring Inclusiveness for Older Adults in the National Toilet Revolution Initiative

China has the world’s largest population aged 65 years or older, with nearly 210 million older adults in 2024, representing nearly 15% of its 1.4 billion total population (United Nations, 2024). Proactively responding to population aging has been proposed as China’s national policymaking priority since the 1990s when the proportion of older adults was just around 5%, which was later incorporated into its national economic and social development plans (Zou et al., 2024). While China has made significant progress in mainstreaming aging in various policy domains, this paper advocates further enhancing such strategy in its overall efforts to modernize social governance, especially integrating age-friendly lavatory facilities in the national Toilet Revolution initiative, both in private family households and in public places. In this article, we start with a brief review of the approach to mainstreaming aging and then introduce population aging trends in China and its practice of mainstreaming aging. We then move to the case of developing age-friendly lavatory facilities in the ongoing national Toilet Revolution. We first discuss the functional disabilities of older adults and propose that the needs of older people in this regard should be incorporated into its ongoing national Toilet Revolution initiative. We conclude with concrete recommendations for improving inclusiveness for older adults in the Toilet Revolution. We call for more policy efforts to mainstream aging to improve the social governance of population aging in China. Mainstreaming aging is a policymaking strategy recommended by the Madrid International Plan of Action on Ageing in 2002, which refers to the integration of aging issues into the mainstream agenda of economic, social, cultural, and policy development, ensuring that all policies, plans, and programs adequately consider the needs, rights, and contributions of older populations (United Nations, 2002; United Nations Economic Commission for Europe, 2021). As an approach to social governance, mainstreaming aging is necessary for any society in the face of population aging. Changes in demographic structure alter the foundational parameters for societies to function and operate. Population aging thus demands a systemic revamp of the social institutions (Rowe & Kahn, 2015). The notion of mainstreaming aging is evolving to cover digital inclusiveness and multicultural integration. The application of technology, artificial intelligence, and big data, along with greater attention to gender differences and the needs of minority groups, is reshaping the practice of mainstreaming aging. Particularly after the COVID-19 pandemic, there is a heightened global emphasis on strengthening older adults’ health resilience, social adaptability, and intergenerational cooperation (United Nations, 2023; United Nations Economic Commission for Europe, 2021). China is on a rapid track of population aging, with the proportion of persons aged 65 years or older rising from 5.3% in 1990 to 14.7% in 2024, to 30.9% by 2050 and 45.8% by 2100, as projected by the United Nations (United Nations, 2024). It took China only 25 years to double its proportion of older people from 7% to 14% and the same number of years to double from 14% to 28%, much shorter than the 40 to 100 years that most developed nations took or will take to witness such demographic transitions (Gu et al., 2021; Zou et al., 2024). One challenging issue resulting from population aging in contemporary China is that among approximately 23 million older persons who require assistance for performing activities of daily living (ADL), about half of them are not able to meet their care needs. These 2 numbers are projected to be more than doubled by 2050 (Zou et al., 2024). Another more pressing issue is the rapidly increasing number of oldest-old persons aged over 80 years in China, who usually have great demands for care, which appears more worrisome. The proportion of oldest-olds currently accounts for around 2.5% of the total population but is projected to quadruple to over 10% within the next 30 years (Zou et al., 2024). The Chinese government started to address aging issues in the early 1980s. However, only in the 1990s did the Chinese government realize the transformation of the whole society is necessary to address population aging and thus developed strategies to “proactively respond to population aging,” officialized by the national five-year plan in 2001 and highlighted as a top-level national strategy in 2019 to address aging issues as well to modernize social governance (Du & Wang, 2018; Zou et al., 2024). Over the last few decades, China has implemented comprehensive policies and practical measures to address population aging and also made critical efforts to mainstream aging in various policy domains (Du and Wang, 2018). Along this general direction, the social governance of China has seen broad transformations in the past few decades. The old-age care services in China, traditionally featuring family care, are now socialized and marketized (Zou et al., 2024). The government has actively promoted the role of the community in old-age care and encouraged the development of old-age care sectors in the market. The national social security system has been revamped, and the government developed public pension and medical insurance schemes, key areas for the later lives of the Chinese, separately for the rural and urban regions, and recently made tremendous efforts for integration (Gu et al., 2021). In recent years, more and new problems and issues of population aging have been raised in policymaking, which is closely related to the changes in China’s whole social governance system, such as health management of the entire life cycle, intergenerational harmony and equity, sustainability of the pension system, and development of family and society (Du & Wang, 2018). Responding proactively to population aging, China has made remarkable progress in modernizing its governance of aging issues via mainstreaming aging. Yet, it still faces challenges, such as the imbalanced development between regions and between rural and urban areas. Moreover, China needs to further upgrade its policies and practices on equitable resource distribution and support systems, such as more age-friendly public infrastructure designs and construction, including accessible toilet facilities in homes and public restrooms, which are essential for fulfilling the basic daily needs of older people (Liu et al., 2020). Next, we will discuss the functional disability of older adults as an exemplary field to illustrate the potential of further mainstreaming aging in China. One of the primary health outcomes in later life is functional disability. Population aging is a significant force that drives the increase of disability in our world. Disability is an umbrella term for impairments, activity limitations, and participation restrictions (WHO, 2001). In the existing literature on functional disability, the index of ADLs is often adopted as a significant measurement, which checks the difficulty or dependency in basic self-care activities such as eating, bathing, dressing, toileting, and indoor transferring (Katz et al., 1963). Functional disability of older adults, as measured by ADLs, is thus directly associated with the demands of care and sits on the center stage for policy concerns over population aging. Policymakers and researchers have made substantial endeavors to understand and address functional disability of older adults. One important topic is to monitor the trends of functional disability among older people as the essential intelligence for public planning on the cost of aging care. Empirical evidence has shown that disability trends of older adults significantly vary between and within nations. Accordingly, multiple theoretical models have been proposed with contrasting scenarios, such as compression of morbidity, expansion of morbidity, and dynamic equilibrium (Robine & Michel, 2004). Some researchers developed a comprehensive framework, summarizing most of the related factors on disability trends (Gu et al., 2015). The ADL-based disability has also been introduced to transform the concept of life expectancy, a key policy and research tool to study active or healthy aging (Gu et al., 2021). Health expectancy was coined to describe the average number of years with a healthy condition, commonly free of ADL disability, that a person at a given age (or at birth) is expected to live throughout his or her remaining lifetime. According to the Global Burden of Disease (GBD) study, the life expectancy at birth of Chinese is 77.6 years at birth and 68.5 years disease-free and disability-free life expectancy at birth in 2019, rising from 68.1 years and 60.5 years in 1990, respectively (GBD Project Team, 2020). In the following sections, we will show how functional disability, a central topic for policymaking and related research on population aging, could be better mainstreamed into China’s Toilet Revolution. The idea of the Toilet Revolution originated from the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) in 1990, and the term was officialized in the mid-1990s, which advocates ensuring that every child has sanitation facilities against infectious diseases and pollution (Cheng et al., 2018; UNICEF East Asia and Pacific Regional Office (EAPRO), 2020; WHO/UNICEF JMP, 2025). It was part of the efforts to reduce child mortality and improve child health, a core part of the international agenda after the Second World War. The focus on children was gradually expanded to general development. In 2015, the international community adopted the 2030 Agenda for Sustainable Development, which proposed 17 sustainable development goals, in which sustainable development goal 6.2 claims to achieve access to adequate and equitable sanitation and hygiene for all and end open defecation by 2030. Notably, many NGOs, such as the World Toilet Organization and the Bill & Melinda Gates Foundation, also play active roles in this global movement (World Bank, 2018). This movement not only addresses sanitation needs for children but also has significant implications for older adults, as access to clean and age-friendly sanitation facilities is crucial for maintaining dignity, independence, and overall health in aging populations, highlighting the importance of a life-course perspective in policy and health interventions. Today, the Toilet Revolution has been widely adopted by the governments of developing nations as a developmental mission, particularly for their rural areas (World Toilet Organization 2024; Zhang et al., 2023). Take Asia as an example. Bangladesh’s sanitation promotional efforts originated in the 1960s, before culminating in a remarkably successful National Sanitation Campaign from 2003 to 2006 that saw 85% of households using “improved” standard latrines in 2015, up from 33% using “hygienic latrines” in 2003 (Hanchett, 2016). During this time frame, the country also cultivated an unaccepting view toward open defecation among the population, shifting away from what was once a prevalent toileting behavior and significantly reducing its prevalence. Similarly, India launched the Swachh Bharat Mission in 2014, a large-scale, multipronged policy intervention aimed at eliminating open defecation wherein emphasis was placed on rural areas not only to upgrade toileting facilities but also to tackle the prevalent preference for open defecation (Gupta et al., 2019). Such emphasis on toileting in rural areas in national sanitation efforts may also be observed in Indonesia and the Philippines with the Sanitasi Total Berbasis Masyarakat program and the Philippine Approach to Sustainable Sanitation, respectively (Lapid, 2012; Hirai et al., 2018). China’s Toilet Revolution can be traced throughout its modern history. Back in the 1930s, Zhou Gucheng, a renowned historian, once described his well-known dream for the future of China: for every Chinese person to have access to a flushing toilet (Shen et al., 2019). Since the 1950s, the government of China has had rounds of social campaigns to promote general hygiene and sanitary conditions in China, including improvements in toilets (Cheng et al., 2018). The formal term Toilet Revolution in Chinese and its relevant discussion appeared in the late 1980s (Zhu, 1988), earlier than the UNICEF and WHO’s JMP initiative. In the 2000s, the Toilet Revolution in China was further expedited. In 2015, China launched a nationwide movement of Toilet Revolution driven by the central government, aiming to address the inadequate state of public sanitation facilities and those in tourism sites, and it is now linked to major national initiatives such as “Healthy China 2030,” a national plan on improving the health and well-being of Chinese people, and “rural vitalization,” a national proposal to develop rural areas. In the past decade, China has made significant improvements in this movement. For example, more than 120,000 public toilets in urban areas and about 10 million toilets in rural areas were built or upgraded from 2015 to 2020 (Wang, 2020). Smart toilets equipped with sensors to monitor health metrics and emergency alarms are growing in many cities (Cerambath, 2024). Furthermore, a public toilet cloud platform has been in place since 2017, which displays the locations and real-time data for more than 270,000 public toilets in 346 cities, allowing users to locate nearby available restrooms through real-time data updates (Que, 2018). The Toilet Revolution not only transformed public facilities but also has driven substantial improvements of toilet facilities in family households. According to the Chinese censuses, in cities, over 95% of family households had access to a private sanitary toilet, a significant increase from just 50% in 2000; in rural areas, less than 6% of family households did not have access to toilet facilities in 2020, down from 30% in 2000 (National Bureau of Statistics of China [NBSC], 2002, 2022). While China has made significant progress in its Toilet Revolution initiative, we call for more integration of the needs of older people in this national movement to better accommodate older people further in the ongoing Toilet Revolution, which aligns with the perspective of mainstreaming aging. Indeed, in recent years, the aging-friendly design of toilet facilities has already been called for by several cities in China (e.g., Chaozhou Government, 2023; Chen, 2023; Wang, 2023). While China has made significant progress in its Toilet Revolution initiative, we call for more integration of the needs of older people in this national movement to better accommodate older people further in the ongoing Toilet Revolution, which aligns with the perspective of mainstreaming aging. It is theoretically sound that the Toilet Revolution is related to older people, as difficulty in toileting is one of the major ADL disabilities in later life (Purser et al., 2012). Disability has been routinely understood in the medically oriented model, in which disabled people are considered as those with long-term physical, mental, intellectual, or sensory impairments. By contrast, the social model of disability highlights the disabling effects of social, political, and environmental barriers and prejudice. In the disablement process model (Verbrugge & Jette,1994), the main pathway of disablement, starting from pathology and impairment, is argued to be affected by a series of extra-individual factors, including built, physical, and environmental factors. Among all types of ADL disability, disability in toileting is probably the most socially and environmentally dependent. After all, for toileting, humans of modern societies develop distinct social manners and construct specific spaces and facilities. When people start to be frail in later life, the role of social and environmental factors may rise significantly, interacting with body function to determine if the individual can accomplish this essential daily task (Liu et al., 2020). In this sense, any initiative committed to improving the condition of toileting should pay attention to this special group of people. This underscores the importance of a life-course approach, recognizing how early-life experiences, environmental design, and social support systems shape an individual’s ability to maintain independence in toileting as they age. Accommodating the needs of older people in the Toilet Revolution is crucial in China. China has encouraged rural-urban migration and rapid urbanization since the 1980s. As a result, the proportion of the urban population in China reached over 68% in 2024, rising from 27% in 1990 (NBSC, 1992, 2025). Accordingly, in rural China, population size has been experiencing a rapid decline, with accelerated population aging due to rural-urban migration (Feng et al., 2019). The fact that population aging is more rapid and substantial in rural China reminds us of the urgency of paying attention to the aging issues in the Toilet Revolution, both for private family households as well as in public places, since users of newly built toilets could mostly come from people of older ages. How should China’s Toilet Revolution better accommodate the needs of older adults? Research provides valuable insights. The 2014 Thousand-Village which and rural aged years or older, that of older Chinese still 30% toilets and only indoor (Liu et al., 2020). remarkable progress in the Toilet Revolution, in 2020, 14% of households still on and indoor with in regions (NBSC, 2022). recent nationwide further that only of urban older adults and of rural older adults that there was a public toilet in their community in and that of urban older adults and of rural adults that their toilets to meet their needs Research on 2024). These inadequate conditions significant for China in improving the life of older adults and further the mainstreaming of the aging toileting, for example, can increase the of especially in toilets can disabilities in frail at older ages. to and indoor toilets are essential to and for older adults. Research using the on global and health further that rural older adults toilets double the of toileting difficulty with those with toilets & 2021). the Toilet Revolution with could significantly improve the of life for older adults in rural China. a few major to promote in China’s Toilet Revolution. in toilet infrastructure between urban and rural areas, as well as between and regions, a critical While urban and more areas better and rural and less developed regions often indoor systems, or older adults in rural areas to and conditions that and health The digital further the equitable of age-friendly toilet populations from toilet but rural older adults, often less may be from using modern lavatory facilities. In public toilet are China’s in the Toilet Revolution, inadequate and the of toilet in rural and to of newly built facilities in regions et al., 2023). the of age-friendly toilets governments have introduced policies to aging-friendly toilet as the of comprehensive data on the number and distribution of such facilities policymaking and progress could the progress of mainstreaming aging within the Toilet Revolution. further mainstream aging in China’s national Toilet Revolution initiative, a approach is recommended to equity, and the needs of older adults, particularly those with functional the integration of age-friendly into the design, and of both public and private sanitation facilities. We thus have the following policy age-friendly design in toilet is toilets should emergency assistance systems, and accessible to accommodate older adults with or toilets should also have and designs to support older adults. policies should such for new toilet and of existing particularly in rural and regions infrastructure and assistance should be expanded in the Toilet Revolution to older adults, particularly those in or upgrade age-friendly toilets at between government private and should be further to resource and the of the most programs could be implemented to develop models to up strategies community and campaigns should be considered critical in age-friendly in the Toilet Revolution. public about the importance of age-friendly toilets can greater of and support for older adults’ needs. can play a role in ensuring and maintaining new facilities. should be in toilet to infrastructure The integration of such as for or systems, can the and hygiene of toilets for older adults. The Toilet should be further expanded to all public toilets urban and rural areas, integrating real-time data to and better the entire population, particularly older adults. 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