THE ancient virtue of filial piety means children should care for frail elderly parents at home and sending them to a nursing home is considered shameful abandonment. But as China ages, home care is impossible. Zhang Qian investigates.

Three weeks ago, 78-year-old Chen Genfu stumbled and fell in his own kitchen, breaking his leg and turning his three adult children's lives upside-down.

Well aware of their filial obligations, the three who are middle-aged, have done a good job over the years of visiting their father frequently and arranging for necessities since their mother died. But his broken leg raises an urgent question for which there's no easy answer.

Now Chen needs round-the-clock care for months to come, but none of his children can spare the time to tend him, since all of them have to work.

They had an idea but no one wanted to be the first to say it aloud: a nursing home.

Sending an elderly person to an assisted-care facility or nursing home, if they really need it, may be a difficult but accepted option in the West. But in China, sending an elderly parent to be cared for by strangers is almost unthinkable - it's the worst kind of unfilial behavior. People make all kinds of sacrifices to care for their elderly relatives.

"Raising children for one's old age" is an ancient tradition since there was no social system or facilities to support people when they could no longer work. Their children, more precisely their filial sons, were expected by parents, family and society to support their parents.

But this kind of filial piety has become almost impossible because of the rapid aging of the Chinese population, undermining of the extended family and one-child family planning policies that reduce the number of offspring to support elderly parents. The group of people who need care is growing much larger compared with the diminishing size of the group of care givers.

Thus, it is inevitable that society must marshal its resources, tap new resources and play a much larger and more active role in caring for China's elderly, many expert say. It's not too soon to start.

The China Ministry of Human Resources and Social Security recently proposed a "flexible" retirement plan that aims to address the problem and give time for society to get prepared and for individuals to get used to the idea of institutional care and other options.

"It is a big problem for the world, and it is exaggerated in China," according to Catherine Gilliss, dean of the Nursing School of Duke University who delivered a speech at a long-term care forum in Shanghai two weeks ago.

China's decision to control its population size with its widely applied one-child policy for more than 30 years has changed the demographics and age structure.

There are many more people who live longer today, yet fewer people to take care of them.

There are more than 100 million elderly (officially defined as 60 years old or above) people in China and the number increases by more than 3 percent a year, which is five times the growth of the general population.

That's the conclusion of the report Construction Plan of the Social Senior Care Service System (2011-2015) released in late 2011. It estimates that the elder population will reach 221 million by 2015, accounting for 16 percent of the total population.

The pressure is even greater in Shanghai, as the 3rd Shanghai Senior Work Conference heard in May. Shanghai's elderly (now around 3.48 million of 60 or above, accounting for 24.5 percent of the total population) will grow by 200,000 annually on average from 2011-2015, double the growth of the previous five years 2006-2010.

After 2013, more than 80 percent of the new elderly population will be parents of an only child, which clearly demonstrates that the tradition of senior care by the younger generation is impossible. Without enormous help and resources, a two single children cannot care for four in-laws, two on each side of the family.

The aging problem is approaching so fast that Chinese society and individuals are not fully prepared either psychologically and in terms of material resources, according to Wu Bei, professor of nursing and global health at Duke University, who conducted extensive research on long-term care in Chinese cities.

"If you ask the Chinese families around, you will find that a nursing home is often the last resort for the family, since most of them still think it shameful to send or be sent to a nursing home, as it suggests abandoning and being abandoned in terms of traditional values," Wu says. "Another fact is that even if they are willing to make that decision, there is always a long waiting list for the good public nursing homes that they would prefer."

By the end of 2010, China had only 3.5 million beds in 101,000 public senior care facilities (local government and community based) - only enough to provide for less than 2 percent of its elderly. And the government nursing homes with better facilities and lower cost are even more limited.

To address this situation, the 12th Five-year Plan (2011-2015) suggests a senior care system that is largely based on home-based care, supported by community care, and supplemented by organization care. In Shanghai, the structure is characterized as "9073," meaning 90 percent of seniors get home-based care with the help of family members or trained nursing workers, 7 percent get community nursing service, such as day care centers and "meals on wheels" program, while 3 percent rely on nursing homes.

The plan places considerable importance on long-term care at home, yet there are few trained nurses or nurse's aids available on the market to work in homes, according to Wu, the professor from Duke University. An unskilled house maid or ayi is often all that is available.

This is what happened to Chen Genfu after he broke his leg. His family had no choice but to hire a 24-hour maid to care for him. But she hasn't done very well since she has no skills in tending to injured patients.

Even in nursing facilities, most workers have little education and the experience in nursing is limited. Consider the various facilities in Shanghai's Changning District. The staff with more than three years' nursing experience represents only 26.7 percent of the total, while senior professionals are only 10 percent, according to Peng Jianming, vice president of Civil Affairs Department of Changning District.

By September 2011, there were 554 nursing workers in 34 nursing facilities in Changning, of whom 241 only had primary school education while 97 were illiterate.

"You don't need a PhD nurse staying at home all day to take care of an elderly person, but you do at least need somebody who has the skills for elder care. This means they can prevent falls and burns, make the environment safe and give basic care for certain diseases," says Gilliss, the dean of nursing at Duke University. "You can train people to do those jobs and it will be meaningful work for many."

Cooperation between the professionals and private enterprises is helping in Shanghai in the past few years, though there are still very few private companies involved.

Shanghai Huoban (Partner) Home-based Care Service Co, started in 2009 in Pudong New Area, is one of the first private home-based care service companies in the city, according to its founder Yang Lei. The company cooperates with local hospitals to give professional assessments of elderly clients' health condition and needs, prescribe particular services and train nursing workers. Each staff member is certified.

"Though the service is greatly needed by the elderly and everybody says there is a big market here, not many such private services have emerged over the years," Yang says, adding that he only knows of two in Pudong so far.

Obstacles to service

Low profit and limited support by the government are the major obstacles for the company, Yang says. Elders who are poor can only receive government subsidies if they go to public nursing homes, where access is almost impossible due to few beds and long waiting lists. The private service company, meanwhile, also must pay the social welfare allowance of its staff, which is also covered by the government in public nursing homes.

"We cannot charge too much since most of the seniors who need care cannot afford the cost, while operating costs are high," Yang says.

The situation has improved somewhat in recent years, since the government has recognized the need and encourages private enterprises, community groups and NGOs to participate in senior care, according to Wang Yanni, founder of Qingsong (Pine Tree) Home-based Care Service Co started in 2009 in Beijing. It expanded to Shanghai last month.

Apart from certain city government allowances for early operations, most local community officials are also willing to help private care service companies in various ways.

"It takes time for the government to fine-turn the system, and we are patient since we know that we are doing the right things," Wang says.

The peak demand for senior care is yet to come in Shanghai, Yin Zhigang, vice dean of the Shanghai Research Center on Aging, told a local newspaper. Most of the new elderly in Shanghai now are actually "young" old people (considered younger than 80) who can still manage to care for themselves in most cases. But these "young" old people will get old in 20 years, putting even greater pressure on the senior care system. This is the time for action, not complacency.

"China traditionally has so much respect for the elderly, which makes it a very urgent task for the country to face and cope with the population aging problem, lest we should one day become incapable of taking care of the ones we think we should," says Gilliss.