Improving Long-Term Senior Care in an Aging Society

Multiple chronic diseases and other complex conditions, such as dementia, make addressing the need for high-quality long-term care for senior persons even more important. Photo exclusively licensed to the Asian Development Bank until 2019.

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A structured development approach is helping create a sustainable pool of highly qualified eldercare professionals in the People’s Republic of China.


The growing health care needs of older persons in aging societies pose both challenges and opportunities.

In the People’s Republic China (PRC), a rapidly aging population with a high risk of chronic diseases and the decline in family-based care have increased the demand for long-term eldercare services and facilities. In response, the government adopted policies that promote the development of the eldercare market, which increased the number of senior care centers. Yet there is still a lack of facilities, and qualified geriatric nurses and caregivers continue to be scarce especially in rural areas.

A project supported by the Asian Development Bank in 2016 helped a province in the PRC to bridge the supply gap in eldercare services by carrying out capacity building and a three-tiered training system for nurses. Liaoning is one of the first provinces in the country to become an aging society, where more than 7% of the population are over 65 years old. In just 2 years, the province has become a center for geriatric education and training with eldercare experts promoting project practices and experiences nationwide

This case study shares lessons learned from the project that can help countries with the same problems. It is adapted from Caring for Carers in Liaoning Province: Strengthening Elderly Workforce in the People’s Republic of China.


In 2018, more than 22% of the population of Liaoning was over 65 years old, 56.9% of the older adults suffer from chronic diseases, and about 13.4% of them are disabled. In 2017, it had only 25 beds for every 1,000 people in eldercare institutions. A 2012 study showed that only 6.9% of nurses in the province had certified geriatric nursing qualifications, compared with the national average of 10%. Not only was there an acute shortage of nurses, but there was also inadequate training in geriatric care.

The same situation is happening across the PRC. The challenge lies in changing the concept of geriatric nursing from simply “curing” older persons in the short term to “caring” for them over the long term so they can age with dignity.


The number of people over 60 years in the PRC is projected to surge to 480 million or 34% of the population by 2050 from 249 million in 2018.

Figure 1: Three-Tiered Senior Care System in the People’s Republic of China

Source: Author’s estimates; China Daily. 2019. China’s Care for the Elderly Boosts Silver Economy. 8 October.

The Chinese government has put in place a three-tiered senior care system (Figure 1): home-based care or “aging in place,” community-based care, and institutional-based care. The government targets is changing its role from being a direct supplier and provider to “purchaser and regulator” of eldercare services. Some provinces and municipalities, including Beijing and Shanghai, have announced that setting up senior care centers no longer requires government permits. These developments as well as a decline in family-based care have given rise to a sunrise industry in nursing homes and eldercare institutions. Privately run senior care centers now make up 44% of the total number of centers in the PRC.

However, the PRC does not pay enough attention to geriatric nursing education at both basic and continuing education levels. Geriatric nursing is often offered merely as an elective course for a graduate nursing degree. Most direct caregivers in long-term care institutions are hired off the labor market and lack training in caring for older persons, much less for those with chronic diseases and complex conditions.

In addition, geriatric care is not considered a rewarding career because of low pay and job instability.


It is equally important to increase the pool of eldercare professionals in long-term care institutions and to ensure that they can provide safe and competent care for older persons. Achieving this goal in Liaoning province required a two-pronged approach.

Capacity building on long-term care education and training

A team of experts was formed in 2017 to implement eldercare policy research and training projects in the province. The team comprised consultants from Chiba University (Japan) and medical and nursing experts from the First Affiliated Hospital of China Medical University.

The experts were armed with tools (i.e., SWOT Analysis, Jiro Kawakita or KJ Method) to examine and analyze the problems, anticipate the needs of the market, and come up with appropriate education and training plans.

Three-tiered eldercare training system

The project created a system that classified professionals into three groups, each with their corresponding training modules (Figure 2).

Figure 2: Liaoning Province’s Hierarchical Approach to Training Aged Care Professionals

Source: Author’s representation.

As a structured approach to development, the three-tiered training system begins with training the eldercare nursing experts (Level 3), updating their concept of senior care services, and then incorporating the teaching or training methods and content they learned into the initial curriculum system they created for the eldercare teachers (Level 2).

Eldercare teachers undergo a 4-week training course, comprising 120 hours of theoretical training, and practice classes totaling 40 hours. The Level 2 group will then train caregivers (Level 1), applying a similar format of theoretical and practical learning.


The team of eldercare experts of Liaoning Province accomplished the following:

  • Developed the guidelines, standards, and implementation framework for the geriatric nursing training program, including admission criteria for teacher trainees, training standards, evaluation and assessment standards, and goals and timetables for the short, medium, and long term.
  • Created content for courses, training modules, and materials for the geriatric nursing training course system and training program for eldercare, and set up a standard evaluation system for trainers.
  • Trained nursing managers and teachers on using the KJ Method and incorporated it into the post-graduate nursing course of the China Medical University. The method is applied to clinical nursing quality analysis and to solve existing problems.

Over the 2 years that the project was implemented, the eldercare experts (Level 3) were able to raise the status of Liaoning as a center for geriatric education and training. They promoted their project practices and experiences nationwide. They also produced a book based on their training programs, focusing on humanistic care for older persons.


Experience and results from the project can help guide research on human resource development for eldercare and efforts to ensure that senior care institutions provide safe and competent services.

The PRC needs to address the largest gap in the eldercare workforce, which is at the lowest level, the caregivers. Not only do they lack proper training, but they also need better compensation and job stability. They should be given incentives to undergo training and apply for accreditation.

The three-tiered training method, together with an effective evaluation and regulatory framework, can help improve the quality and supply of eldercare services. There is a need to establish quality standards across the continuum of long-term services including home, community, and residential eldercare.

Develop hospitals and nursing homes as training bases for teaching and training eldercare workers. They can provide not only theoretical training but also enable the trainees to put geriatric care concepts into practice.

Najibullah Habib
Senior Health Specialist, Human and Social Development Sector Office, Sectors Group, Asian Development Bank

Najibullah Habib is a senior health specialist in ADB. He has more than 20 years of international experience in international public health and development with global institutions. He is a physician with a doctorate degree in Public Health.

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