SFG3777 World Bank-financed Anhui Aged Care System Demonstration Project Social Impact Assessment Report (For Review) Commissioned by: Department of Civil Affairs of Anhui Province Prepared by: China Three Gorges University Prepared in: November 2017 1 Table of Contents 1. Introduction ............................................................................................................................................. 8 1.1 Project overview ............................................................................................................................ 8 1.2 Social impact assessment overview ............................................................................................. 12 1.2.1 Tasks of social impact assessment .................................................................................... 12 1.2.2 People to be surveyed for the assessment .................................................................. 12 1.2.3 Details of social impact assessment ........................................................................... 13 1.2.4 Social impact assessment methods ............................................................................ 14 2. Social and economic circumstances of the project area......................................................................... 20 2.1 The project area ........................................................................................................................... 20 2.2 Profile of the population of the project area ................................................................................ 21 2.2 Social and economic circumstances of the project area............................................................... 22 2.2.1 GDP .................................................................................................................................. 22 2.2.2 Per capita GDP ................................................................................................................. 23 2.2.3 Per capita disposable income ............................................................................................ 24 2.3 About the aged-care service sector of the project area................................................................. 26 2.3.1 Aged-care facilities ........................................................................................................... 26 2.3.2 Beds for aged-care service ................................................................................................ 32 2.3.3 Workers in aged-care service industry .............................................................................. 33 2.3.4 Funding source for the aged-care service industry ........................................................... 34 2.3.5 Aged-care service mode.................................................................................................... 35 2.4 Policy environment for construction of integrated aged-care service system in the project area 39 2.4.1 Overview on policies concerning construction and management of domestic diverse aged-care service system ........................................................................................................... 40 2.4.2 Specific policies of the project area on construction and management of diverse 2 aged-care service system (taking Anqing for instance) ............................................................. 49 2.5 Overview on poverty in the project area...................................................................................... 52 2.5.1 Overview on urban and rural poverty in the project area.................................................. 52 2.5.2 Existing poverty alleviation strategies in the project area................................................. 54 2.5.3 Role of this project in poverty alleviation......................................................................... 55 3. Main social benefits brought by the project .......................................................................................... 56 3.1 The project implementation can create employment opportunities, especially the opportunities for the women.................................................................................................................................... 57 Construction of the aged-care service standard system ............................................................. 59 3.2 The implementation of the project will change the traditional view on aged-care service & promote social transformation ........................................................................................................... 60 3.3 The implementation of the project will improve the overall management and service capacity of Anhui provincial government on the diversified aged-care service system....................................... 61 3.4 The implementation of the project will greatly enhance the capacity of home-based aged-care service in project area ........................................................................................................................ 65 3.5 The implementation of the project will enhance capabilities of professional care services and management within the project area .................................................................................................. 71 4. Stakeholder analysis .............................................................................................................................. 79 4.1 Identification of stakeholders ...................................................................................................... 80 4.2. Interest demands of primary stakeholders in this project ........................................................... 87 4.2.1 Administrative and implementation departments of the project—civil affairs departments at various levels ......................................................................................................................... 87 4.2.2 Supervising and directing departments—other relevant government departments ........... 90 4.2.3 People occupied in aged-care services.............................................................................. 91 4.2.4 The aged and their family members.................................................................................. 92 4.2.5 Various social organizations providing aged-care services ............................................... 92 3 4.2.6 Residents and cadres of relevant communities ................................................................. 93 4.3 Benefits, benefited and damaged groups in this project .............................................................. 95 4.3.1 Component 1--Comprehensive supporting capability of the provincial aged-care service95 4.3.2 Component 2—Community home-based aged-care service ............................................. 96 4.3.3 Component 3—Professional nursing service and management ........................................ 97 4.3.4 Component 4--Project management, monitoring & evaluation, and capacity building .... 98 4.3.5 Major damaged groups ..................................................................................................... 98 5. The impact of the project on aged-care service workers ..................................................................... 100 5.1 Basic conditions of aged-care service workers .......................................................................... 100 5.1.1 Gender and age ............................................................................................................... 101 5.1.2 Educational level ............................................................................................................ 103 5.1.3 Post, position and title .................................................................................................... 105 5.1.4 Working years and income ............................................................................................. 106 5.1.5 Marital status .................................................................................................................. 109 5.2 The impact of the project on aged-care service workers............................................................ 110 5.2.1 Positive impact ............................................................................................................... 110 5.2.2 Negative impact .............................................................................................................. 112 5.2.3 The social impact that the aged-care service workers concern most............................... 113 5.2.4 The impact difference of sub-projects on aged-care workers in different cities ............. 115 6. Influence of the Project on the Aged and Their Family Members .................................................. 120 6.1 Influence of the project on the aged who have received the aged-care service and their family members ............................................................................................................................... 121 6.1.1 Basic information of the aged who have received the aged-care service ................ 121 6.1.2 Influence of the project on the aged who have received the aged-care service and their family members .............................................................................................................. 130 6.2 Potential influence of the project on the aged not receiving the aged-care service and 4 their family members ...................................................................................................................... 133 6.2.1 Potential influence of the integrated medical and aged-care service project on the aged not receiving the aged-care service ................................................................................. 133 6.2.2 The potential impact of the integrated medical and aged-care service project on the family members ....................................................................................................................... 141 6.2.3 Potential Impact of the Project Transformation and Upgrading of Nursing Home on the Uncared Elderly................................................................................................................. 148 7. Impact of the Project on Other Stockholders .................................................................................. 157 7.1 Impact of the Project on Civil Affairs Departments at All Levels .................................. 157 7.2 Impact on the Aged-care Institutions .............................................................................. 158 7.3 Impact on Other Residents of Communities ................................................................... 160 8. Gender Analysis of the aged Care Service Workers ....................................................................... 160 8.1 Overview of the Female Aged-care Service Workers of Project .................................... 161 8.2 Cognition and Attitude of the Female Aged-care Service Workers to the Project .......... 162 8.3 Attitude and Suggestion of the Female Aged-care service Workers to the Project......... 163 8.4 Impact of the Project on the Women in the Project Area ................................................ 165 8.4.1 Impact on the Female Aged-care Service Workers in the Project Area .................. 165 8.4.2 Influence on potential female aged-care service workers in the project area .......... 166 9 Identification of World Bank’s safeguard policies.......................................................................... 167 9.1 Identification and analysis of ethnic minorities............................................................... 167 9.1.1 Identification basis .................................................................................................. 167 9.1.2 Identification method .............................................................................................. 168 9.1.3 Identification result ................................................................................................. 168 9.1.4 Judgment on preparation of ethnic minority development plan .............................. 169 9.2 Identification and analysis of resettlement influence ...................................................... 170 9.2.1 Identification basis .................................................................................................. 170 5 9.2.2 Identification method .............................................................................................. 170 9.2.3 Identification result ................................................................................................. 170 9.2.4 Judgment on preparation of resettlement plan, due diligence report and policy framework ............................................................................................................................... 172 10. Information disclosure and public consultation ...................................................................... 173 10.1 Information disclosure and public consultation in preparation period ............................ 173 10.1.1 Notification and publicity of information about the project .................................... 173 10.1.2 Field investigation ................................................................................................... 174 10.1.3 Questionnaire .......................................................................................................... 176 10.1.4 Interview with key informants ................................................................................ 176 10.1.5 Depth interview ....................................................................................................... 177 10.1.6 Focus group symposium.......................................................................................... 177 10.2 Results of public consultation ......................................................................................... 177 10.2.1 Cognition and evaluation of aged-care service workers on project......................... 177 10.2.2 Cognition, attitudes and requirements of the aged receiving care on the project .... 181 10.2.3 The attitude and understanding of the aged without care and their family members to the project ............................................................................................................................ 184 10.2.4 Implement the public consultation plan .................................................................. 189 10.2.5 Grievance mechanism ............................................................................................. 191 11. Social management plan and implementation ......................................................................... 193 11-1 Social management plan.................................................................................................. 193 11.1.1 Reasonably arrange the spatial location of the aged care sites in community ......... 193 11.1.2 Reduce the workload of government staff............................................................... 193 11.1.3 Reduce the negative impact of the project on aged-care service workers ............... 193 11.1.4 Reduce the negative impact of the project on the aged ........................................... 194 11.1.5 Reduce the negative impact on other residents in community ................................ 194 6 11.1.6 Reduce the resettlement influence of the project..................................................... 195 11.1.7 Establish the grievance mechanism ......................................................................... 195 11.1.8 Vigorously publicize the World Bank-financed Projects ........................................ 195 11.1.9 Vigorously cultivate the ability of the social work organizations and volunteer organizations to provide community aged-care service .......................................................... 196 11.1.10 Give priority to women in terms of opportunities ........................................... 196 Reduce the negative impact of the project on aged-care service workers during its implementation ........................................................................................................................ 197 Reduce the negative impact of the project on the aged during its implementation ................. 197 11-2 Monitoring and evaluation .............................................................................................. 199 Appendix 1. Process of Social Survey ......................................................................................... 200 7 1. Introduction 1.1 Project overview In October of 2014, approved by the State Council, the National Development and Reform Commission and the Ministry of Finance jointly promulgated the Notice on Issuing the Request for the Instructions from the National Development and Reform Commission and the Ministry of Finance on Using the Proposal for the Alternative Projects Financed by the World Bank in 2015-2017 Fiscal Years (FGWZ.[2014]No.2284). According to the Notice, the Anhui Aged Care System Project ("the project" for short) has been included in the list of the proposed alternative projects financed by the World Bank in 2015-2017 fiscal years. The Proposed Development Objective(s) of this project is to support the government of Anhui Province in establishing and managing a diversified (public and private) system of delivery of aged-care services, including home, community and residential services, that serves both urban and rural elderly. The main development objectives of the project are as follows: 1) Strengthening the capacity of the government of Anhui Province to exercise stewardship over the diversified aged-care service delivery system; 2) Strengthening the delivery capacity of the diversified service provision systems of aged-care delivery in five municipalities (Anqing, Lu An, Wuhu, Suzhou, and Xuancheng) in Auhui province. 3) Improving the balance of aged-care services in five municipalities in Anhui province; 4) Improving the affordability and quality of aged-care services in five municipalities in Anhui province. The project has four components: 1. Supporting the development of government stewardship capacity for the aged-care system; 2. Strengthening the delivery and 8 management of community and home-based services; 3. Strengthening the delivery and management of nursing care; and 4. Project management, capacity building, and monitoring and evaluation. (See Table 1-1). Table 1-1 The components of the project Components Details Building elderly-care data centers; developing integrated service Developing platforms for aged-care, including data collection platform, service comprehensive management platform, information disclosing platform, and aged-care information service application platform; establishing a province-wide unified system for standard for the information system; upgrading of aged-care aged-care information management system. Creating a system Establishing standards for evaluating the ability and care demands of for ability and the elderly; developing the evaluation tools; trainings to the Component demands evaluation institutions and personnel; implementation of the 1 assessment of the evaluation and so on. elderly Developing Developing a general service standard and service provision standard standard service system, a service management standard system, a service quality systems guarantee standard system, and a service evaluation standard system. Building the Training aged-care providers and the management of aged-care capacity of facilities; training the management of the department of civil affairs to aged-care improve their management capabilities. providers Anqing plans to build 127 community home-based care service stations through decoration, renovation and equipment procurement, including 26 in Daguan District, 12 in Economic Development Zone, 60 in Yixiu District and 29 in Yingjiang District. They are to be used for serving the home-based elderly with household registration in Anqing. According to the investigation, these stations will have construction area of about 59,915m2. It is tentatively determined that Community-based full-time service centers will have 500 beds in total. care service Lu An plans to build 34 community home-based care service stations stations through decoration, renovation and equipment procurement (19 according to the investigation for the time being and 15 will be supplemented in the later period). It is tentatively determined that the stations will have construction area of 18,281m2. The service stations Component have day-care service center, lounge and recreation center, library and 2 study room, room for health-keeping and rehabilitation and so on. The service centers will have 510 beds in total for the time beings. The services purchased by the Anqing Municipal Government encompass seven items: aged-care service for the five-guarantees that are supported in a decentralized way, home-based aged-care service for the low-income elderly, respite service, care service for the Government low-income disabled elderly with dementia, ability evaluation for the purchased low-income elderly, empty-nest elderly visiting service and other services aged-care services. No civil works and decoration are involved in this project. The services purchased by the Lu An Municipal Government include five items: caring service for the urban empty-nest elderly, ability/demands evaluation for the elderly of above 65 years old, 9 Components Details service purchase for the elderly people with economic difficulties, home-based respite service for the disabled elderly, and the third party supervision for the project implementation. Interim evaluation and later period evaluation are also implemented in the project implementation. No civil works and decoration are involved in this project. Wuhu plans to contrast or reconstruct seven community care centers (including construction of one new home for the elderly, decoration Embedded center and renovation of one nursing home and five community care for disabled and centers), reconstruct (decorate and renovate) one training center and semi-disabled recreational and sport center for the elderly, one central kitchen and elderly one big health management information data center. The total construction area is 66,150.55m2, and new construction of 36966.2m2 and 1,243 beds will be added. This project is located in First People’s Hospital of Anqing in Longshan. The planned total area is 54,000m2 (equivalent to about 81mu) and a construction area of 42,459.4m2 will be added. The project contents include: medical and aged-care comprehensive service center, living center for aged-care, family recreation center, medical care center for disabled and semi-disabled elderly, hospice center, professional training base for the aged-care providers, and Medical and aged nutritional catering center. Upon the project formation, totally 1,000 care combined beds will be added. center In the Traditional Chinese Hospital of Lu An, a multi-functional medical building will be built and equipped with diagnostic, examination, treatment, and rehabilitation equipment. In addition, outdoor roads, squares, green belt, and water supply and drainage and power supply systems will be built. The total construction area of the building is 92,100m2; 600 additional beds will be arranged in the Component building. 3 In Ningguo (under the jurisdiction of Xuancheng City), a public welfare service center will be built on the land of the existing welfare home. The project contents will include: construction of new elderly service sub-center, decoration and renovation of the cultural activity sub-center named "Longevity Paradise", and improvement of the ancillary and supporting facilities. The total construction area will be 15,684m2, including decoration and renovation of the “Longevity Paradiseâ€? of 6,630m2, construction of new elderly service sub-center Urban welfare and canteen of 9,004m2; reconstruction of the gate and guard’s room home of 50m2. 260 new beds will be added. In the Xuanzhou District under the jurisdiction of Xuancheng city, the existing welfare homes will be relocated and rebuilt. The living equipment, medical rehabilitation equipment, security equipment and vehicles will be purchased; the roads, parking lot, green belt, outdoor sport ground, water supply and drainage system, elevator system, fire control system and electronic system and other auxiliary system will be constructed. The total construction area will be 19500 ㎡ and 400 new beds will be added. The existing 35 rural nursing facilities in Yongqiao District, Dangshan County, Lingbi County, Xiao County, Si County will be Rural nursing expanded and upgraded, including expansion, decoration and facilities renovation of the original buildings as well as equipment upgrading. The total construction area will be 42,905m2 and added construction area is 27,033m2. 1446 new beds will be added. 10 Components Details Project management, Component Including results monitoring and evaluation; project management and monitoring and 4 institutional capacity building. evaluation and capacity building 11 1.2 Social impact assessment overview To ensure that the project is implemented in accordance with the World Bank's safeguard policies, the Involuntary Resettlement Research Center of China Three Gorges University (the "Center" for short), commissioned by the Department of Civil Affairs of Anhui Province, will analyze the social impact of this project under the leadership of Xiao Ping and Sheng Sanhua. 1.2.1 Tasks of social impact assessment The main tasks of this social impact assessment are: 1) identifying the stakeholders of the project and analyzing their requirements for the project and the project's impact them; 2) helping improve the proposed project design and implementation plan, so that the individuals and groups directly affected by the project can be supportive of the project and participate in it; 3) minimizing or preventing the negative impact of the project in order to ensure that the proposed development objective(s) of the project will be achieved and the social benefits brought by the project will be increased; 4) putting forward a feasible social management plan, so as to lay the basis for the project monitoring and evaluation during and after the project implementation. 1.2.2 People to be surveyed for the assessment This social impact assessment involves five municipalities: Lu An, Suzhou, Xuancheng, Anqing, and Wuhu. The people to be surveyed for the social impact assessment include the workers and management of aged-care facilities who are directly affected by the project; the elderly and their families who receive the services provided by aged-care facilities; and the elderly and their families who are potentially affected by the project and do not receive the services provided by aged-care facilities. 12 1.2.3 Details of social impact assessment The potential stakeholders of the project and its social impact will be analyzed for the social impact assessment in accordance with the relevant national policies and the World Bank’s policies OP4.10 and OP4.12. This social impact assessment involves: (1) Stakeholder analysis: identifying the key stakeholders of the project; conducting project activities and encouraging key stakeholders to participate in them; soliciting opinions and advice from the stakeholders and obtaining the information about the project's impact on them through discussion meetings and/or surveys, and analyzing these opinions, advice, and impact; assessing the potential positive and negative impact of the project; analyzing the social risks that the project may cause and seeking for solutions to mitigating the risks. (2) Information disclosure and public consultation: paying close attention to the disclosure of the project-related information when building the aged-care system, along with the impact that construction may cause and the grievance mechanism; the details and methods of the public consultation in which the affected persons participate, and their opinions and advice on the establishment of integrated aged-care system. (3) Identification of displaced persons and ethnic minorities: identifying the land used for the project in accordance with the World Bank's involuntary resettlement policy OP4.12; preparing a resettlement action plan or due diligence report as required by the World Bank if land acquisition or structure demolition is involved; checking the project area to see if there are any ethnic minorities in line with the World Bank's policy OP4.10 and determining whether a development plan for ethnic minorities is needed. (4) Impact of the project implementation to the key stakeholders: the social impact assessment will not only focus on the impact of the project implementation to the workers and management of aged-care facilities, and the elderly and their families who receive the services provided by aged-care facilities, but also focus on the responses to the impact. 13 1.2.4 Social impact assessment methods From March 1st to March 17th of 2017 and from June 28th to July 3rd of 2017, the social impact assessment team, supported by the Project Management Offices (PMOs) at different levels, conducted surveys in Hefei, Lu An, Suzhou, Anqing, Wuhu, and Xuancheng with regard to the social impact of the project. The team primarily uses qualitative methods, such as document study, discussion meetings, in-depth interviews, and interviews with key informants, along with quantitative methods such as questionnaire surveys, to compare and corroborate the document and data it has obtained, so that the social impact assessment results can reflect the fact. (1) Data studies. The documents and data that the team refers to include: â‘  the statistical yearbooks and reports that reflect the economy and society of the project area; the sixth population census data; the documents concerning the social surveys of ethnic minorities; â‘¡the documents concerning the establishment of integrated aged-care system; the basic information of the Department of Civil Affairs of Anhui Province and the project area with regard to the aged-care programs; â‘¢ other relevant data and documents, such as the work report of relevant departments; proposals and feasibility study reports for the project; and compensation standards for land acquisition and house demolition. (2) Questionnaire. Socio-economic surveys are conducted in the form of questionnaire. The questionnaire is designed based on the project activities, the characteristics of the project affected persons (PAPs), and the details of the social impact assessment; the questionnaire is conducted by way of random sampling. The questionnaire contains the basic social and economic information about the affected persons, their satisfaction with aged-care facilities, and their understanding and expectations of the project. The affected persons to be surveyed in the form of questionnaire are divided into two groups: aged-care service providers/managers; and the elderly and their families. 1) Questionnaire for the survey of aged-care providers/managers From March 1st to March 17th of 2017, the social impact assessment team gave 158 questionnaires to the aged-care providers/managers from 23 community care stations/centers, rural nursing facilities, and urban social welfare homes in the five municipalities. All 158 questionnaires were answered. 14 Table 1-1 Sample questionnaire for the survey of the affected workers/managers of aged-care facilities Valid Community-base questionnaires Quantity of Valid City County/district d stations/nursing as a questionnaires questionnaires facilities percentage of (number) (number) (number) total questionnaires Jin'an District 4 16 16 100% Lu An Yu'an district 4 20 20 100% Yongqiao 2 10 10 100% District Xiao County 1 8 8 100% Suzhou Dangshan 1 14 14 100% County Lingbi county 1 10 10 100% Si County 1 8 8 100% Yixiu District 1 4 4 100% Daguan District 1 4 4 100% Yingjiang Anqing 1 6 6 100% district Development 1 2 2 100% Zone Wuhu Jinghu District 3 20 20 100% Xuanzhou 1 14 14 100% Xuancheng District Ningguo City 1 22 22 100% Total 23 158 158 100% SPSS software is used in building and analyzing the database for the questionnaire. See table 1-2 for the basic information of valid questionnaires Table 1-2 Basic information of the valid sample questionnaire for the survey of the affected aged-care providers/managers Gender Males account for 35.4%; females account for 64.6%. Age The average age is 48; the youngest age is 22; the oldest age is 79 Ethnicity Han Chinese accounts for 100%; no ethnic minorities are involved. Primary education receivers account for 20.25%; junior high school graduates Level of account for 30.38%; senior high school / technical secondary school graduates education account for 18.99%; higher vocational college graduates and above account for 5.6%. 15 Marital People who are married account for 88.61% (of which, 3.6% are widowed and no status one is divorced); people who are single account for 11.39%. Nursing staff account for 43%; administrative and support staff account for 29.1%; Job others account for 17.7% people whose monthly incomes are less than 1,000 Yuan account for 6.3%; people whose monthly incomes fall between 1000 Yuan and 2000 Yuan account for 36.7%; Income people whose monthly incomes fall between 2000Yuan and 4000 Yuan account for 55.7%; people whose monthly incomes fall between 4000Yuan and 6000 Yuan account for 1.3%. Religion 8.86% of the surveyed people have religious beliefs (Buddhism). 2) Questionnaire for the survey of the affected elderly and their families (a) Questionnaire for the survey of the directly affected elderly and their families From March 1st to March 17th of 2017, the social impact assessment team gave 172 questionnaires to the elderly and their families who are directly affected by the project from 22 community care stations/centers, rural nursing facilities, and urban social welfare homes in the five municipalities. All 172 questionnaires were answered. Table 1-3 Basic information of the sample questionnaire for the survey of the directly affected elderly and their families Valid Community-base questionnaires Quantity of Valid d stations/nursing as a City County/district questionnaires questionnaires facilities percentage of (number) (number) (number) total questionnaires Jin'an District 4 18 18 100% Lu An Yu'an district 4 20 20 100% Yongqiao 2 14 14 100% District Xiao County 1 8 8 100% Suzhou Dangshan 1 12 12 100% County Lingbi county 1 10 10 100% Si County 1 16 16 100% Yixiu District 1 10 10 100% Daguan District 1 4 4 100% Yingjiang Anqing 1 8 8 100% district Development 1 4 4 100% Zone Wuhu Jinghu District 2 12 12 100% Xuanzhou 1 20 20 100% Xuancheng District Ningguo City 1 16 16 100% Total 22 172 172 100% SPSS software is used in building and analyzing the database for the questionnaire. See table 1-4 for the basic information of valid questionnaires 16 Table 1-4 basic information of the valid sample questionnaire for the survey of the directly affected elderly and their families Gender Males account for 37%; females account for 63%. Age The average age is 76; the youngest age is 49; the oldest age is 96 Ethnicity Han Chinese accounts for 100%; no ethnic minorities are involved. Primary education receivers account for 69.6%; junior high school graduates account for 8.9%; senior high school / technical secondary Level of education school graduates account for 16.5%; higher vocational college graduates and above account for 5%. People who are married account for 84.4% (of which, 33.8% are married Marital status people whose spouses are alive and 50.6% are widowed; no one is divorced); people who are single account for 15.6%. People who are fully able to take care of themselves account for 55.6%; people who are basically able to take care of themselves account for Self-care ability 24.7%; people who are partially able to take care of themselves account for 14.8%; people who are unable to take care of themselves account for 4.9% People who have no source of income account for 23.4%; people whose monthly incomes are less than 1,000 Yuan account for 36.4%; people whose monthly incomes fall between 1000 Yuan and 2000 Yuan account Income for 13%; people whose monthly incomes fall between 2000Yuan and 4000 Yuan account for 26%; people whose monthly incomes fall between 4000Yuan and 6000 Yuan account for 1.3%. "San Wu people" elderly who have lost the ability to work, have no source of income, and have no legal guardians to support them account Type of elderly for 30.3%; elderly who are in financial difficulties and are disabled (or mentally challenged) account for 5.3%; other elderly account for 51.3% Religion 4.9% of the surveyed people have religious beliefs (Buddhism). Having People who have children account for 66.2%; people who are childless children/childlessness account for 33.8% (a) Questionnaire for the survey of the potentially affected elderly and their families From June 28th to July 3rd of 2017, the social impact assessment team gave 224 questionnaires to the elderly and their families who are potentially affected by the project from 1 hospital, 2 communities, and 3 townships in the two of the five municipalities. Of the 224 questionnaires, 214 are answered (172 are answered by elderly while 42 are answered by their families); valid questionnaires account for 95.5% of the total. Table 1-5 Basic information of the sample questionnaire for the survey of the potentially affected elderly and their families Percentage of The main Quantity of Valid valid The places City County/district items questionnaires questionnaires questionnaires surveyed surveyed (number) (number) to the total questionnaires Lu An City Impact of the Hospital of integrated Traditional medical and Lu An Jin'an District 128 118 92.2% Chinese aged care Medicine; service Ren Min Xin project; the 17 Cun elderly who Community are not in the institutional Zhongshi aged-care Sub-district recipients, and their families Impact of integrated medical and aged care service Qing'an project; the Community Yu'an district elderly who 42 42 100% in the Gulou are not Sub-district institutional aged-care recipients, and their families Impact of the upgrading of rural nursing Zhenbei facilities; the Yongqiao Village of elderly who 20 20 100% District Beiyangzhai are not Township institutional aged-care recipients Gaozhai Suzhou Village and Impact of the Houzhu upgrading of Village of rural nursing Fengmiao facilities; the Town; Lingbi county elderly who 34 34 100% Qiumiao are not Village and institutional Hongguang aged-care Village of recipients Yangtuan Town Total 224 214 95.5% Note: the elderly who are not institutional aged-care recipient refer to the elderly who have not received services from aged-care facilities Table 1-6 basic information of the valid sample questionnaire for the survey of the potentially affected elderly Gender Males account for 71%; females account for 29%. Age The average age is 69; the youngest age is 50; the oldest age is 92 Ethnicity Han Chinese accounts for 100%; no ethnic minorities are involved. Primary education receivers and below account for 54.7%; junior high school graduates account for 27.9%; senior high school / technical Level of education secondary school graduates account for 10.5%; higher vocational college graduates and above account for 7%. Marital status Married people whose spouses are alive account for 66.2%; people who 18 are widowed account for 23.3%; people who are divorced account for 4.7%; and people who are single account for 5.8%. People who are fully able to take care of themselves account for 60.5%; people who are basically able to take care of themselves account for Self-care ability 30.2%; people who are partially able to take care of themselves account for 5.8%; people who are unable to take care of themselves account for 3.5% The average monthly income is 1718Yuan. People whose monthly incomes are less than 1,000 Yuan account for 29.3%; people whose monthly incomes fall between 1000 Yuan and 2000 Yuan account for Income 25.6%; people whose monthly incomes fall between 2000Yuan and 4000 Yuan account for 37.8%; people whose monthly incomes stand at 4000 Yuan or above account for 7.3% "San Wu people" elderly who have lost the ability to work, have no source of income, and have no legal guardians to support them account for 5.8%; the elderly who are in financial difficulties and are disabled (or Type of elderly mentally challenged) account for 2.3%; the elderly who have low incomes and are able to take care of themselves account for 26.7%; other elderly account for 65.1% Religion 3.3% of the surveyed people have religious beliefs (Buddhism). Having People who have children account for 91%; people who are childless children/childlessness account for 9% Table 1-7 basic information of the valid sample questionnaire for the survey of the elderly's families who are potentially affected by the integrated medical and aged care service project Gender Males account for 47.6%; females account for 52.4% Age The average age is 46; the youngest age is 23; the oldest age is 74 Ethnicity Han Chinese accounts for 100%; no ethnic minorities are involved. Primary education receivers and below account for 25%; junior high school Level of graduates account for 30%; senior high school / technical secondary school education graduates account for 20%; higher vocational college graduates and above account for 25%. Married people whose spouses are alive account for 76.2%; people who are Marital widowed account for 4.8%; people who are single account for 19%; no one is status divorced The average monthly income is 3088 Yuan. People whose monthly incomes are less than 1,000 Yuan account for 23.5%; people whose monthly incomes fall between Income 1000 Yuan and 2000 Yuan account for 17.6%; people whose monthly incomes fall between 2000Yuan and 4000 Yuan account for 23.5%; people whose monthly incomes stand at 6000 Yuan or above account for 11.8% Farmers account for 15%; workmen account for 5%; self-employed traders account for 15%; general business employees account for 5%; people who work at Job governments or government-affiliated institutions account for 20%; retired or jobless people account for 35%; others account for 5% Religion % of the surveyed people have religious beliefs (Buddhism). Having or People who have no siblings account for 23.8%; people who have siblings account not having for 76.2% siblings (3) Discussion meeting: â‘ holding discussion meetings for the relevant government departments in the cities which the project involves in order to get their opinions and advice on the establishment of integrated aged-care system and understand the 19 potential impact of the project implementation on them; â‘¡ holding discussion meetings at aged-care facilities for their workers and managers as well as for the elderly and their families, in order to understand the potential impact of the project on them and their opinions on and requirements for the project. (4) In-depth interview: conducting face-to-face interviews with the affected persons (the workers and managers of aged-care facilities as well as elderly and their families) in the project area, so as to obtain the information about the following aspects: the affected persons' lives and financial conditions; the positive and negative impact of the project to them; the potential risks posed by the project to them; and their attitudes, advice, and expectations on the project. (5) Interviews with key informants: interviewing the heads of relevant government departments and aged-care facilities as a way to get their opinions and advice on the project, so as to provide advice on social impact management for the project. 2. Social and economic circumstances of the project area 2.1 The project area The area of the World Bank-financed Anhui Aged Care System Project ("the project" for short) can be divided into three administrative levels: at the first level is Anhui Province; at the second level are the five municipalities (Lu An, Suzhou, Anqing, Wuhu, and Xuancheng) in Anhui Province; and at the third level are 14 districts/counties where the project (component) implementing units are located. The project areas are generally in the southeast, west, and north of Anhui Province. The analysis of the project areas and the financial support that the project receives from local governments focuses on the project area at the second level. In 2015, the project area at the second level covered a total of 56,733 square kilometers, accounting for 40.52% of the area of Anhui Province; the permanent urban residents and registered population of the second-level project area were 22.802 million and 26.54 million, accounting for 37.12% and 38.19% respectively of that of Anhui Province. 20 The second-level project area covers both developed cities (such as Wuhu) and underdeveloped cities (such as Lu An and Suzhou); it also involves both urban and rural areas. 2.2 Profile of the population of the project area The outflow of population (labor) from the project area is quite noticeable; the aging rate (the number of people aged 60 and above as a percentage of the number of permanent urban residents) of the project area is rather high. In 2015, the total number of permanent urban residents in the second-level project area was 22.802million, accounting for 85.92% of the registered population of the area. Of the 22.802 million, the number of people aged 60 and above stood at 4.266 million, accounting for 18.71% of the total number of permanent urban residents in the project area, which was higher than the number of people aged 60 and above as a percentage (15.5%) of China's total number of permanent urban residents; the number of people aged 65 and above stood at 2.5266 million, accounting for 11.08% of the total, which was 1.07% higher than the number of people aged 65 and above as a percentage of China's total number of permanent urban residents. See table 2-1 for details. Table 2-1 Profile of the population of the project area in 2015 Unit: 10,000 persons, % People aged 60 and People aged 65 and above above As a As a Indicator Number of percentage percentage permanent Registered of the of the Region urban population Population number of Population number of residents permanent permanent urban urban residents residents Lu An City 577.5 717.7 100.6 17.42 52.19 9.04 Suzhou City 554.1 649.5 104.3 18.82 64.95 11.72 Anqing City 524.0 622.1 75.3 14.37 55.52 10.60 Wuhu City 365.4 384.8 69.7 19.07 44.13 12.08 Xuancheng City 259.2 279.9 76.7 29.59 35.86 13.83 Project area 2280.2 2654 426.6 18.71 252.66 11.08 Anhui Province 6143.6 6949.1 1062.2 17.29 720.64 11.73 China 137462 137462 21307 15.5 13884 10.1 21 Source of data: The data about registered population and the number of permanent urban residents comes from the National Economic and Social Development Statistics Bulletin of China, Anhui Province, and the project area in 2015; the data about the number of people aged 60/65 and above in Anhui province comes from the 2016 Statistical Yearbook of Anhui Province; the data about the number of people aged 60/65 and above in China comes from the 2015 National Economic and Social Development Statistics Bulletin of China. 2.2 Social and economic circumstances of the project area From the perspective of the GDP (Gross Domestic Product), the per capita GDP, and per capita disposable income, the economic level of the project area is significantly lower than the average economic level of China and Anhui Province; the project area is generally underdeveloped. Moreover, the economic disparity in the project area is relatively large. For instance, the economic level of Wuhu and Xuancheng is generally higher than that of Lu An, Suzhou and Anqing. 2.2.1 GDP In 2015, the GDP of the second-level project area totaled 742.13 billion Yuan, accounting for 33.72% of the GDP of Anhui Province. Of the 742.13 billion Yuan, 245.73 billion is the GDP of Wuhu, accounting for 33.11% (highest among all five municipalities) of the GDP of the project area; 97.15 billion Yuan is the GDP of Xuancheng; and 114.34 billion Yuan is the GDP of Lu An. See Table 2-2 for details. Table 2-2 Economic circumstances of the project area in 2015 Urban per Rural per Per capita Per capita capita capita Indicator GDP disposable GDP disposable disposable income income income Region 100 million Yuan Yuan Yuan Yuan Yuan Lu An City 1143.4 19885 14710 22238 9074 Suzhou City 1235.8 22415 14748 23631 9140 22 Anqing City 1613.2 29840 16331 23966 9854 Xuancheng 971.5 37610 20553 28602 12309 City Wuhu City 2457.3 67592 24521 29766 15964 Project area 7421.2 32027 17411 25309 10397 Anhui 22005.6 35997 18363 26936 10821 Province China 676708 49351 21966 31195 11422 Source of data: The 2015 National Economic and Social Development Statistics Bulletin of different regions 2.2.2 Per capita GDP In 2015, the per capita GDP of the second level project area stood at 32,072 Yuan (about 5,150 USD), accounting for 64.99% and 89.1% of the per capita GDP of China and Anhui Province respectively. The per capita GDP of Wuhu and Xuancheng was 67,592 Yuan (about 10,853 USD) and 37,610 Yuan (about 6,039 USD) respectively; the per capita GDP of Lu An was 19,885 Yuan (about 3,193 USD), the lowest among all five municipalities. See Figure 2-1 and Table 2-2 for details. 中国 49351 安徽çœ? 35997 项目区 32072 芜湖市 67592 宣城市 37610 安庆市 29840 宿州市 22415 六安市 19885 0 10000 20000 30000 40000 50000 60000 70000 80000 Source of data: Table 2-2 Figure 2-1 Per capita GDP of the project area in 2015 (unit: Yuan) 中国 China 安徽çœ? Anhui Province 项目区 Project Area 芜湖市 Wuhu City 宣城市 Xuancheng City 安庆市 Anqing City 宿州市 Suzhou City 六安市 Lu An City 23 2.2.3 Per capita disposable income In 2015, the per capita disposable income of the project area was 17,411 Yuan (about 2795 USD), accounting for 79.3% and 94.8% of the per capita disposable income of China and Anhui Province respectively. The per capita disposable income of Wuhu and Xuancheng was 24,521 Yuan (about 3937 USD) and 20,553 Yuan (about 3300 USD) respectively, which was significantly higher than the average per capita disposable income of Anhui Province; the per capita disposable income of Lu An, Suzhou, and Anqing was less than 2,500 USD, which was significantly lower than the average per capita disposable income of China, Anhui Province, and the project area. See Table 2-2 and Figure 2-2 for details. 中国 21966 安徽çœ? 18363 项目区 17347 芜湖市 24521 宣城市 20553 安庆市 16331 宿州市 14748 六安市 14710 Source of data: Table 2-2 Figure 2-2 Per capita disposable income of the project area in 2015 (unit: Yuan) 中国 China 安徽çœ? Anhui Province 项目区 Project Area 芜湖市 Wuhu City 宣城市 Xuancheng City 安庆市 Anqing City 宿州市 Suzhou City 六安市 Lu An City In 2015, the urban per capita disposable income of the project area was 25,309 Yuan (about 4,064 USD), accounting for 81.1% and 94.0% of the urban per capita disposable income of China and Anhui Province respectively. The urban per capita 24 disposable income of Wuhu and Xuancheng was 29,766 Yuan (about 4,779 USD) and 28,602 Yuan (about 4,592USD) respectively, which was higher than the average urban per capita disposable income of Anhui Province but lower than that of China; the urban per capita disposable income of Lu An, Suzhou, and Anqing was significantly lower than the average urban per capita disposable income of China and Anhui Province. See Table 2-2 and Figure 2-3 for details. 中国 31195 安徽çœ? 26936 项目区 25309 芜湖市 29766 宣城市 28602 安庆市 23966 宿州市 23631 六安市 22238 Source of data: Table 2-2 Figure 2-3 Urban per capita disposable income of the project area in 2015 (unit: Yuan) 中国 China 安徽çœ? Anhui Province 项目区 Project Area 芜湖市 Wuhu City 宣城市 Xuancheng City 安庆市 Anqing City 宿州市 Suzhou City 六安市 Lu An City In 2015, the rural per capita disposable income of the project area was 10,397 Yuan (about 1,669 USD), which was close to the rural per capita disposable income (10,821 Yuan) of Anhui province. The rural per capita disposable income of Wuhu and Xuancheng was 15,964 Yuan (about 2,563 USD) and 12,309 Yuan (about 1,976 USD) respectively, which was higher than the average rural per capita disposable income of China and Anhui Province; there was no big gap between the rural per capita disposable income of Lu An, Suzhou, and Anqing. See Table 2-2 and Figure 2-4 for details. 25 中国 11422 安徽çœ? 10821 项目区 10397 芜湖市 15964 宣城市 12309 安庆市 9854 宿州市 9140 六安市 9074 Source of data: Table 2-2 Figure 2-4 Rural per capita disposable income of the project area in 2015 (unit: Yuan) 中国 China 安徽çœ? Anhui Province 项目区 Project Area 芜湖市 Wuhu City 宣城市 Xuancheng City 安庆市 Anqing City 宿州市 Suzhou City 六安市 Lu An City 2.3 About the aged-care service sector of the project area 2.3.1 Aged-care facilities 1) The quantity of aged-care facilities The main aged-care facilities in the project area are residential facilities (retirement homes, nursing homes, welfare homes, etc.) along with community and home-based care facilities. The number of aged-care information service facilities is small. Besides, the number of community- and home-based care facilities that actually provide aged-care services is also small. In 2016, there were 963 aged-care facilities in the project area, accounting for 36.73% of the total number of aged-care facilities in Anhui province. Of the 963 aged-care facilities, residential facilities account for nearly 90%. The number of aged-care facilities in Lu An, Suzhou, and Anqing was 251, 250, and 220 respectively. See 26 figure 2-5 for details å…»è€?机构数（个） 项目区 963 宣城市 134 芜湖市 108 安庆市 220 宿州市 250 六安市 251 0 100 200 300 400 500 600 700 800 900 1000 Source of data: Department of Civil Affairs of Anhui Province Figures 2-5 - 2-9 and table 2-3 are similar to this. Figure 2-5 The number of aged-care facilities in the project area in 2016 å…»è€?机构数（个） Aged-care facilities (number) 项目区 Project Area 宣城市 Xuancheng City 芜湖市 Wuhu City 安庆市 Anqing City 宿州市 Suzhou City 六安市 Lu An City There are 375 licensed aged-care facilities in the project area, accounting for 38.94% of the total number of licensed aged-care facilities in Anhui province; more than 60% of the aged-care facilities are not licensed. Most (214) of the licensed aged-care facilities are located in Suzhou, accounting for 57.07% of the licensed aged-care facilities in the project area. See figure 2-6 for details. 27 250 60.00 50.00 200 40.00 150 30.00 100 20.00 50 10.00 0 0.00 六安市 宿州市 安庆市 芜湖市 宣城市 已许å?¯å…»è€?机构数（个） 26 214 63 25 47 已许å?¯å…»è€?机构å? æ¯”（% ） 6.93 57.07 16.80 6.67 12.53 Figure 2-6 The number and percentage of licensed aged-care facilities in the cities of the project area in 2016 六安市 Lu An City 宿州市 Suzhou City 安庆市 Anqing City 芜湖市 Wuhu City 宣城市 Xuancheng City 已许å?¯å…»è€?机构数（个） The number of licensed aged-care facilities The number of licensed aged-care facilities as a 已许å?¯å…»è€?机构å? æ¯”（%） percentage of the total number of aged-care facilities 2) Property rights and the nature of aged-care facilities Most of the aged-care facilities in the project area are public ones; the number of private aged-care facilities (including state-funded but privately run ones and privately funded and run ones) is small, but such facilities are rapidly growing. In 2016, there were 710 public aged-care facilities in the project area, accounting for 73.73% of all aged-care facilities in the project area. Of the 710 public aged-care facilities, 216 are in Lu An, accounting for 86.06% of all aged-care facilities in this city; the public aged-care facilities in Suzhou account for 66% (the lowest percentage among all five municipalities) of all aged-care facilities in this city. See figure 2-7 for details. 28 300 250 35 85 200 66 150 216 42 100 25 165 154 50 83 92 0 六安市 宿州市 安庆市 芜湖市 宣城市 公办公è?¥å…»è€?机构数（个） 社会办（å?«å…¬å»ºæ°‘è?¥ï¼‰å…»è€?机构数（个） Figure 2-7 The number of aged-care facilities in the project area based on their nature and property rights in 2016 六安市 Lu An City 宿州市 Suzhou City 安庆市 Anqing City 芜湖市 Wuhu City 宣城市 Xuancheng City 公办公è?¥å…»è€?机构数（个） The number of public aged-care facilities The number of private aged-care facilities 社会办（å?«å…¬å»ºæ°‘è?¥ï¼‰å…»è€?机构数（个） (including the facilities that are state-funded but privately run) 3) The quantity of beds in aged-care facilities Aged-care facilities in the five municipalities have 141 beds1 on average. In the project area there are 556 aged-care facilities with more than 100 beds, accounting for 57.74% of all aged-care facilities in the project area. The aged-care facilities with more than 100 beds in Lu An and Wuhu account for 68.13% and 66.67% respectively of all aged-care facilities in the two cities; the aged-care facilities with more than 100 beds in Xuancheng account for only 47.01% of all aged-care facilities in this city. See figure 2-8 for details 1 The beds counted do not include the beds for short-term care, the beds for community daycare and the beds for nursing of the medical institutions. 29 180 80.00 160 70.00 140 60.00 120 50.00 100 40.00 80 30.00 60 20.00 40 20 10.00 0 0.00 六安市 宿州市 安庆市 芜湖市 宣城市 100张以上床ä½?å…»è€?机构数（个） 171 134 116 72 63 100张以上床ä½?å…»è€?机构å? æ¯”（% ） 68.13 53.60 52.73 66.67 47.01 Figure 2-8 The number and percentage of aged-care facilities with more than 100 beds in 2016 六安市 Lu An City 宿州市 Suzhou City 安庆市 Anqing City 芜湖市 Wuhu City 宣城市 Xuancheng City 100 张以上床ä½?å…»è€?机构数（个） The number of the aged-care facilities with more than 100 beds 100 张以上床ä½?å…»è€?机构å? æ¯”（%） The number of the aged-care facilities with more than100 beds as a percentage of the total number of aged-care facilities 4) Performance of aged-care facilities Currently the aged-care service market in the project area is still in its infancy, where proper aged-care service models and standards remain to be developed. Moreover, it takes time for the huge potential demand for aged-care services to become real demand. Generally speaking, the overall social and economic benefits of aged-care facilities in the project area fall short of expectations. Most aged-care facilities barely make their ends meet. According to the social impact assessment team, the nature and property rights of the few aged-care facilities1 with good performance are different. 1 Good performance implies good social and economic benefits. Good social benefits means that the elderly and their families are satisfied with aged-care services and aged-care facility beds are mostly used or even in shortage; good economic benefits means that the aged-care facilities' employees are satisfied with their incomes while financial balance or surplus can be achieved, so the employees can work contentedly and the rate of employee turnover will be low 5) Infrastructure of aged-care facilities 30 Currently the aged-care facilities in the project area, especially rural residential aged-care facilities, lack good-quality residential facilities (housing, restaurants, beds, toilets, elevators, bath facilities, and heating equipment); health, medical, and rehabilitation facilities; cultural and recreational facilities; and safety facilities. Only a few residential aged-care facilities2 and community-based aged-care facilities3 are well equipped. 6) Government support for aged-care facilities In order to increase investments into aged-care services, develop aged-care facilities and aged-care service market, and improve aged-care services, local governments in the project area have introduced a number of policies in recent years. First, allowing public aged-care facilities to accommodate the elderly who are not government subsidy recipients, so as to solve the shortage of funds and the problems in sustainable development for these facilities. Second, encouraging and supporting the privatization of public aged-care facilities, so as to maximize the use of public aged-care resources. Third, helping reduce the investments in and operating costs of privately funded and run aged-care facilities, through infrastructure investment, purchase of services, provision of aged-care subsidies to the needy elderly, tax relief, subsidized loans, operating subsidies, fixed asset investment subsidies, subsidies to the establishment of integrated aged-care service information platforms, subsidies to commercial insurance services, subsidies to the training of aged-care providers, and employment subsidies to people who begin to work in the aged-care sector. These measures aim at ensuring and improving the quality of aged-care services, stabilizing and increasing operating incomes, and reducing the investment and operating risks. 2 For example, in Ningguo City, except for the buildings of welfare homes that are included in the project's upgrading program, other buildings are well equipped (excluding medical facilities) 3 For example, in Wuhu City, the Hao Yan Cai Hong and Da Fu community aged-care center (built in 2016) in the Jinghu District is well equipped 31 2.3.2 Beds for aged-care service In 2016, the aged-care service industry in the project area had altogether 136,200 beds1 and there are more than 30 beds for every 1,000 elderly people (above 60 years old). The government-sponsored aged-care service institutions have altogether 90,900 beds, accounting for 66.76% of the total number. The average beds possessed by the social capital invested aged-care service institutions are 179, obviously higher than that of the government-sponsored aged-care service institutions which is 128. Refer to Table 2-3 for details. Table 2-3 Average beds possessed by the aged-care service institutions in the project area in 2016 (unit: sheet) Number of beds Number of beds Number of beds possessed by the possessed by social possessed by the government-sponsored capital invested aged-care service Region aged-care service aged-care service institutions institutions institutions The The The Total Total Total average average average Lu An 32271 129 25273 117 6998 200 Suzhou 31640 127 17653 107 13987 165 Anqing 40792 185 24325 158 16467 250 Wuhu 16304 151 12914 156 3390 136 Xuancheng 15159 113 10742 117 4417 105 Project 136166 141 90907 128 45259 179 area Anhui 366236 140 248821 132 117415 160 Province There are two main problems related to beds for aged-care service in the project area. The first is insufficient beds in the urban areas. Rapid urbanization gives birth to huge demand for reception type aged-care service and it is hard to find a bed in some urban areas of the project area. The second is overall poor quality of beds. The rural reception type aged-care service institutions have crude and shabby beds and no beds 1 The beds counted do not include the beds for short-term care, the beds for community daycare and the beds for nursing of the medical institutions. 32 special for the aged. Some urban aged-care service institutions have newly purchased some higher level beds in recent years. However, they are far from intelligence and automation. 2.3.3 Workers in aged-care service industry The workers in the aged-care service industry in the project do not receive much education, have lower professional skills and are older. According to the survey of the social assessment group of this project 2, the average age of the workers in the aged-care service industry is 45.77; the workers who only received education of junior middle school or below account for more than 50%; the professional technical staffs (with primary technical job title or above) only account for 27.85%; and about 80% of the aged-care service institutions do not have medical staffs, health-keeping staffs and physical therapy staffs. Severe shortage of workers in the aged-care service industry in the project area is one of the key factors restricting development of the aged-care service industry. 1) Shortage of nursing staff The nursing staffs account for the largest proportion among all workers in the aged-care service industry (averagely higher than 40%). Due to the particularity, intensive workload, poor working environment and lower income of the work in aged-care service institutions, not so much people are willing to engage in the frontline service. This leads to severe shortage of nursing staffs, including general nursing staff and special nursing staff. It is prevalent that the government-sponsored reception type aged-care service institutions are severe lack of nursing staff. For instance, Suzhou had altogether 250 aged-care service institutions in 2015, but the total number of workers was only 1622. Averagely, each aged-care service institutions 2 From March 1, 2017 to March 17, 2017, Social assessment group of “World Bank-financed Anhui Diverse Aged-care Service System Projectâ€? (consisting of 6 members) conducted social survey on 23 aged -care service institutions in 15 districts and counties in the project area (including 10 reception type aged-care service institutions and 12 communication care service center/station). The survey object includes the working staffs of the civil affairs departments related to the project implementation, workers in the aged-care service institutions, the elderly people who receive aged-care service and their family members, residents in the community of the community care service center/station and so on. The survey was mainly conducted through discussion meeting and questionnaire. Altogether 330 effective responses were received. 33 had less than 6.5 nursing workers, including the management staffs and logistics support staff. Many persons-in-charge of the aged-care service institutions in the survey expressed that the difficulty in hiring suitable nursing staffs severely affects development of the aged-care service industry. 2) Shortage of professional management staffs China's aged-care service industry is in its infancy. Colleges and universities as well as the training institutions lack cultivation in management staff of aged-care service industry. This leads to shortage of professional management staffs of various aged-care service institutions in the project area. According to survey of the social assessment group, some aged-care service institutions with good economic and social benefits all have outstanding management team or leaders 3 while most of the aged-care service institutions with poor economic and social benefits are lack of outstanding management team or leaders. 3) Shortage of professional technical staffs Because of lack of talents cultivation and supply, lower income and intensive workload, particularity of the service object and lower social status of the work and so on, there is severe shortage of professional technical talents in nursing, psychological communication and counseling, health-keeping and physical therapy and medical care, leading to lower aged-care service level and difficulties in improvement of the service level and development of some aged-care service items. 2.3.4 Funding source for the aged-care service industry The fund for aged-care service industry in the project area comes from diverse channels and mainly from the government (including the central government and local governments), the enterprises and public institutions. The central government of China allocates special fund to support the "San Wu people" (the aged who lost their ability to work, have no source of income and have 3 Such as Ningguo Social Welfare Home, Xuanzhou District Social Welfare Home in Xuancheng City and Yirentang Anqing Yingjiang District Shundao Sub-district Aged-care Service Center which have higher occupancy rate and higher satisfaction degree of the served elderly people. 34 no legal guardians to support them or it is determined that their guardians indeed do not have the ability to support them), the low-income elderly and the disabled and semi-disabled elderly with dementia living in poverty. Fund input by the local governments of the project area into the aged-care service industry mainly comes from the public welfare fund from lottery and the revenue4. The local governments of the project area input the fund to the aged-care service industry by multiple means: first, establishing and constructing various aged-care service institutions; second, paying the basic salary to some workers in government sponsored and operated aged-care service institutions; third, increasing the subsidies to the "San Wu people", the low-income elderly and the disabled and semi-disabled elderly with dementia living in poverty; fourth, purchasing aged-care service from the social aged-care service institutions for some urban elderly people; fifth, offering direct or indirect financial support to development of the aged-care service industry by social capital. With encouragement and support of governments of various level, the local and non-local folk capital invested into the aged-care service industry in the project area is rapidly increased in recent years. Number of the folk aged-care service institutions increases significantly, Zhongcheng Rainbow Aged-care Asset Management Co., Ltd., Changsha Wanzhonghe Community Service Network Company and other famous aged-care service institutions in other provinces have settled in the project area. 2.3.5 Aged-care service mode Diverse aged-care service system is actively planned in the project area in recent years. Various regions are encouraged to explore the suitable aged-care service mode based on the local actual conditions. Currently, there are mainly the following aged-care service modes in the project area. 1) Home-based care service for the aged Home-based care service refers to the socialized service with family as the core, 4 For instance, Suzhou has retained 32,270,000 Yuan public welfare fund of lottery and 19,955,400 Yuan of them are used for aged-care service. 35 community and professional service as the support and with help in daily living activities for the elderly people who lives at home as the main contents. The service includes life care, medical service and spiritual care. There are mainly two types of home-based care service: offering door-to-door care service for the elderly people by the training service personnel and setting up daycare service center for the elderly people in the community to offer the corresponding service. Restricted by the aged-care concept and aged-care facilities, home-based aged-care will be the basic aged-care mode in the project area for quite a long time in the future. Local governments in the project area has formulated and implemented a series of policies to support the home-based care service (such as policy on government procured home-based care service for the urban senior residents) and promoted the establishment and development of community home-based aged-care service institutions. For instance, Lu An Xinde Home-based Care Service Center was set up in March 2016 and Anhui Dongfangjuren Health Management Co., Ltd. was established in August 2016. The newly-built communities in the project area have set up community daycare center (station) or community senior activity center in accordance with requirements of the central government and local governments. However, the service only focus on one aspect (entertainment) and the community home-based aged-care service institutions are small in both quantity and scale and do not run normatively, thus requiring vigorous support. 2) Community care service for the aged Community care service for the elderly people refers to introducing the service of institutional care system and implementing community home-based care service for the elderly people. It combines the advantages and operability of home-based care service and institutional care service and is implemented in the community. It mainly includes offering help in daily living activities, medical care, consolation and entertainment service to the elderly people who lives at home and is suitable for being promoted in cities and towns at present. Lu An, Anqing and Wuhu are vigorously promoting chained community care service for the aged. For instance, Changsha Wanzhonghe Community Service Network Company introduced by Anqing has set up 36 aged-care service center in LashuYuan community, Daguan District and is planning the establishment of other branches of community care service. Its embedded network mode of community care service for the aged (namely the mode which can admit the elderly people permanently) has been included into this project. 3) Institutional care service for the aged Institutional care service for the aged refers to the aged-care service institutions which receive the elderly people (reception type aged-care service institutions) and offer help in daily living activities, nursing, rehabilitation, entertainment and cultural entertainment service to them. The reception type aged-care service institutions include the nursing home and welfare home for the aged and so on. In accordance with Standards of Social Welfare Institution for the Elderly, this type of aged-care service institutions should have living facilities, catering service facilities, cultural entertainment facilities, cleaning facilities, rehabilitation training facilities and medical care facilities. China starts the institutional care service for the aged very early and not a few of urban reception type aged-care service institutions in the project area (mainly are social welfare homes) were established early, have good management system and run very well5. Since the demands for the institutional care service are increased rapidly, some social capital invested reception type aged-care service institutions also run very well6. However, some of urban reception type aged-care service institutions and the majority of rural aged-care service institutions have poor service conditions, few service contents and inferior service quality, thus requiring improvement. Local governments of the project area encourage and support privatization of government sponsored aged-care service institutions and expansion of the scale of social capital invested reception type aged-care service institutions on the one hand and promote the pilot reform of combining the medical care with aged-care and the rehabilitation with aged-care so as to improve the efficiency and quality of institutional care service for the aged on the other hand. Certain progress has been made in combination of medical care and aged-care service 5 Such as Ningguo Municipal Social Welfare Home, Xuanzhou District Social Welfare Home in Xuancheng City 6 Such Fushouyuan in Yixiu District, Anqing 37 in the project area. In 2016, nearly 20% of the aged-care service institutions in the project area have medical institutions. The proportion of the aged-care service institutions that have medical institutions in Xuancheng is relatively larger, i.e. 44.78%, while that of Wuhu and Suzhou is smaller (Refer to Figure 2-9 for the details). The proportion of aged-care service institutions that have medical institutions and are listed institutions of medical insurance in the project area is very small, only 8.1%. However, 19.92% of the aged-care service institutions in Lu An have medical institutions and are listed institutions of medical insurance, which is relatively larger. 600 50.00 45.00 500 40.00 35.00 400 30.00 300 25.00 20.00 200 15.00 10.00 100 5.00 0 0.00 六安市 宿州市 安庆市 芜湖市 宣城市 项目区 安徽çœ? 内设医疗机构的养è€?机构数（个） 52 18 59 3 60 192 567 内设医疗机构的养è€?机构å? æ¯”（% ） 20.72 7.20 26.82 2.78 44.78 19.94 21.62 Figure 2-9 Quantity and proportion of aged-care institutions which have medical institutions in municipalities of the project area in 2016 Number of the aged-care institutions that have 内设医疗机构的养è€?机构数（个） medical institutions Proportion of the aged-care institutions that 内设医疗机构的养è€?机构å? æ¯”（%） have medical institutions (%) 六安市 Lu An 宿州市 Suzhou 安庆市 Anqing 芜湖市 Wuhu 宣城市 Xuancheng 项目区 Project area 安徽çœ? Anhui Province 4) Aged-care information service Building aged-care service information platform, promoting information-based smart aged-care service and providing aged-care related information, especially the information on aged-care market, to the service object, aged-care service institutions 38 and the governmental departments is an aged-care service mode encouraged and supported in the project area. The aged-care service information in the project area can be jointly provided by the governmental departments (with civil affairs department as the dominant)7, professional aged-care service information institutions8 and integral aged-care service institutions with strengths 9 . Currently, unified multi-functional and all-round aged-care service information platform has not been built in the project area and there is only a few of professional aged-care service information institutions which offer fewer services to a small group of people. 5) Integral aged-care service Integral aged-care service refers to that an aged-care service institution with strength provides home-based care service for the aged, community care service for the aged, institutional care service for the aged and aged-care information service in a region. This is regionally monopolistic aged-care service mode. For instance, Wuhu Haoyan-CaihongYuan Aged-care Service (Investment) Management Co., Ltd. plans and builds the integral aged-care service system integrating senile apartment, nursing home, geriatric hospital, community aged-care service network and aged-care service information platform. Construction of the sub-systems have been started and some have been put into operation (Haoyan-CaihongYuan Dafu Community Health and Aged-care Service Center, Haoyan-CaihongYuan TingYuan Community Health and Aged-care Service Center and Wuhu 2912349 Aged-care Service Information Network Platform) 2.4 Policy environment for construction of integrated aged-care service system in the project area In recent years, the State Council and ministries and commissions of the Central Government have promulgated many policy documents to support construction and 7 For instance, Department of Civil Affairs of Anhui Province establishes aged-care service information platform in a planned way. 8 Such as Wuhu Smart Aged-care Service Center 9 Such as Wuhu Haoyan-Caihongyuan Aged-care Service (Investment) Management Co., Ltd. 39 management of diverse aged-care service system10. Local governments of the project area have also formulated and implemented some policies to support construction and management of diverse aged-care service system and some achievements have been made. 2.4.1 Overview on policies concerning construction and management of domestic diverse aged-care service system 1) Comprehensive policy documents on construction and management of diverse aged-care service system Opinions of the State Council on Accelerating Development of the Aged-care Service Industry promulgated on September 6, 2013 (hereinafter referred to as the Opinions) is a document guiding construction and management of diverse aged-care service system in recent years and in the future. The Opinions describe the development objectives, basic principles, basic tasks, basic policy framework and implementation measures of China's aged-care service industry by 2020. In addition, there are Guiding Opinions of the Ministry of Commerce on Promoting Development of the Aged-care Service Industry (Ministry of Commerce, 2014), Measures of Anhui Province for Constructing Urban-rural Aged-care service System (Department of Civil Affairs and Department of Finance of Anhui Province, 2013), Measures of Anhui Province for Constructing Social Aged-care service System (Department of Civil Affairs and Department of Finance of Anhui Province, 2017) and so on. 2) Special policy documents on construction and management of diverse aged-care service system In accordance with the Opinions, relevant laws and regulations and the 13th Five-year Plan for Economic and Social Development of the People's Republic of China, ministries and commissions of the central government and local governments of the 10 The State Council and ministries and commissions of the Central Government have promulgated altogether nearly 80 policy documents related to construction and development of old-age service system from January 2013 to March 2017 and only some highly relevant policy documents will be introduced in this article. 40 project area have promulgated many special policy documents on establishment and management of aged-care service institutions, cultivation of workers in aged-care service industry, construction of aged-care service facilities, subsidies to the aged, pilot reform of aged-care service, development of information-based aged-care service and development of market-oriented aged-care service industry and so on. Refer to Table 2-4 for the details. Table 2-4 Schedule of policy documents pertinent to aged-care service industry promulgated by the central government and local government in recent years Promulgation Year of Level Policy documents department promulgation Opinions of the State Council on Accelerating Development of Comprehensiv State Council 2013 the Aged-care Service Industry e Guiding Opinions of the Ministry of Commerce on Promoting Ministry of 2014 Development of the Aged-care Service Industry Commerce Measures for Permitting Establishment of the Aged-care Ministry of 2013 Service Institutions Civil Affairs Measures for Management of the Aged-care Service Ministry of 2013 Institutions Civil Affairs State Council and ministries and commissions of the central government Opinions of the Ministry of Civil Affairs on Establishing Ministry of Cooperation and Counterpart Support Mechanism of 2013 Civil Affairs Aged-care Service National Development Circular on Organizing and Developing Pilot Work of Remote and Reform 2013 Medical Treatment Policy for Aged-care Service Institutions Commission (NDRC) Circular on Relevant Issues concerning Reduction and Ministry of Exemption of Administrative Charges for Aged-care and Finance, 2013 Medical Institutions NDRC Guiding Opinions of Ministry of Civil Affairs and NDRC on Ministry of Special Promoting Construction of Integrated Community Public Civil Affairs, 2013 Service Information Platform NDRC Circular of the General Offices of Ministry of Civil Affairs and Ministry of NDRC on Developing Pilot Comprehensive Reform of Finance, 2013 Institutional Aged-care Service Industry NDRC Guiding Opinions of the Ministry of Civil Affairs on Ministry of 2013 Promoting Aged-care Service Evaluation Civil Affairs Notice of the General Office of the Ministry of Civil Affairs Ministry of on Carrying out Nationwide Remote Training to Nursing Staff 2013 Civil Affairs for Aged-care Service Office the Notice on Further Strengthening the Preferential Treatment for National 2013 Senior Citizens Committee on Ageing Ministry of Management Measures of the Central Government on Finance, Supporting Rural Happiness Home with Special Public 2013 Ministry of Welfare Fund from Lottery Civil Affairs 41 Ministry of Announcement of Ministry of Commerce and Ministry of Civil Commerce, 2014 Affairs (No.81 in 2014) Ministry of Civil Affairs Ministry of Guiding Opinions on Strengthening Standardization of Civil Affairs 2014 Aged-care Service and etc. Ministry of Opinions on Accelerating Talents Training of the Aged-care Education and 2014 Service Industry other 8 departments Ministry of Finance and Notice on Aged-care Service Procurement of the Government 2014 other three departments Ministry of Circular on Establishing Sound System to Subsidize the Finance and 2014 Disabled Elderly People with Economic Difficulties other two departments Ministry of Notice of the Ministry of Housing and Urban-rural Housing and Development on Strengthening Planning and Construction of 2014 Urban-rural Aged-care Service Facilities Development Ministry of Guiding Opinions on Land Utilization of Aged-care Service Land and 2014 Facilities Resources Ministry of Notice on Facilitating Construction of Urban Aged-care Civil Affairs 2014 Service Facilities and other three departments Ministry of Housing and Notice on Strengthening Barrier-free Transformation of Urban-rural Family Facilities and Public Facilities in Residential Area for 2014 Development the Aged and other four departments Notice on Accelerating Health and Aged-care Service Project NDRC 2014 Ministry of Housing and Guiding Opinions on Strengthening Construction of Rural Urban-rural 2015 Barrier-free Environment Development and other three departments Ministry of Ten regulations on fire safety management of social welfare Civil Affairs 2015 institutions and Ministry of Public Security National Health and Family Guiding Opinions on Combination of Medical Care and Planning 2015 Aged-care Service Commission and other eight departments Guiding Opinions on Standardizing Charging Management of NDRC, Aged-care Service Institutions and Promoting Healthy Ministry of 2015 Development of Aged-care Service Industry Civil Affairs 42 Ministry of Opinions on Encouraging Investment of Private Capital to Civil Affairs 2015 Promote Development of Aged-care Service Industry and other nine departments Ministry of Civil Affairs, Opinions on Supporting Construction of Social Aged-care China 2015 service System with Developmental Finance Development Bank Co., Ltd. Ministry of Housing and Guiding Opinions on Strengthening Construction of Rural Urban-rural 2015 Barrier-free Environment Development and other three departments Ministry of Ten regulations on fire safety management of social welfare Civil Affairs 2015 institutions and Ministry of Public Security Ministry of Notice on Organizing Special Fire Safety Governance of Civil Affairs 2015 Social Welfare Institutions and Ministry of Public Security National Health and Circular on Printing and Distributing Key Task Assignment Family 2016 Plan of Combination of Medical Care and Aged-care Service Planning Commission National Health and Family Notice on Determining the First Batch of National Level Pilot Planning 2016 Units for Combination of Medical Care and Aged-care Service Commission, Ministry of Civil Affairs National Health and Notice on Determining the Second Batch of National Level Family Pilot Units for Combination of Medical Care and Aged-care Planning 2016 Service Commission, Ministry of Civil Affairs Ministry of Notice on Supporting the Pilot Home-based and Community Civil Affairs, 2016 Aged-care Service Reform with Central Government Spending Ministry of Finance Ministry of Circular on Implementing Pilot Home-based and Community Civil Affairs, 2016 Aged-care Service Reform in 2016 Ministry of Finance Ministry of Circular on Determining the Pilot Areas of Home-based and Civil Affairs, Community Aged-care Service Reform supported by Central 2016 Ministry of Government Spending Finance Several Opinions of the General Office of State Council on Opening up the Aged-care Market and Enhancing Aged-care State Council 2016 Service Quality 43 Opinions on Further Improving the System of Assisting and State Council 2016 Supplying the People Living in Extreme Poverty People's Bank Guiding Opinions on Financially Supporting the Accelerated of China and 2016 Development of Aged-care Service Industry other four departments Ministry of Circular on Supporting the Integration of Idle Social Resources Civil Affairs 2016 to Develop Aged-care Service and other nine departments NDRC and Measures for Subsidizing and Stimulating Construction of other two 2016 Aged-care Service System with Central Government Spending departments Miscellaneous Social Service Project Implementation Plan in NDRC 2016 "13th Five-Year" Circular of the General Office of State Council on Printing and Distributing the Development Planning about Aged Education State Council 2016 (2016-2020) Circular on Establishing National Level System to Subsidize Ministry of 2016 the Aged Civil Affairs Circular on Accelerating "Fang-Guan-Fu" Reform of Ministry of Aged-care Service Industry (Fang-Guan-Fu refers to Civil Affairs streamlining administration and delegating more powers to 2017 and other 12 lower-level governments and the society in general while departments improving regulation to optimize the service) Ministry of Circular on Taking Special Actions on Service Quality Civil Affairs 2017 Construction of Nursing Home and other five departments Ministry of Industry and Smart and Healthy Aged-care Service Industry Development Information 2017 Action Plan (2017-2020) Technology and other two departments State Administration Implementation Opinions on Promoting Development of of Traditional 2017 Healthy Aged-care Service of Traditional Chinese Medicine Chinese Medicine Subtotal of the 50 policy documents Department of Civil Affairs of Anhui Measures of Anhui Province for Constructing Urban-rural Province, 2013 Aged-care service System Department of Anhui Province Comprehensive Finance of Anhui Province Department of Civil Affairs of Anhui Measures of Anhui Province for Constructing Social Province, 2016 Aged-care service System Department of Finance of Anhui Province 44 45 Department of Civil Affairs of Anhui Measures of Anhui Province for Constructing Social Province, 2017 Aged-care service System in 2017 Department of Finance of Anhui Province Department of Rules of Anhui Province for Managing the Rural Civil Affairs of 2011 Five-Guarantees Supporting and Service Organizations Anhui Province General Office Implementation Opinions of the General Office of Anhui of the People's Provincial People's Government on Service Procurement from 2013 Government of Social Sectors Anhui Province Department of Measures of Anhui Province for Managing Aged-care Finance of 2013 Institution Anhui Province Department of Measures of Anhui Province for Permitting Establishment of Civil Affairs of 2013 the Aged-care Service Institutions Anhui Province People's Opinions of Anhui Provincial People's Government on Government of 2014 Accelerating Development of the Aged-care Service Industry Anhui Province Department of Notice on Carrying out Aged-care Service Procurement of the Civil Affairs of 2014 Government Anhui Province Department of Catalogue of Anhui Provincial People's Government for Finance of 2014 Guiding Service Procurement from Social Sectors Anhui Province Department of Special Commerce of Opinions of Anhui Provincial People's Government on Anhui Implementing Pilot of Market-based Aged-care Service Province, 2015 Industry Department of Finance of Anhui Province Provisional Rules of Anhui Province for Managing Department of Comprehensive Quota Standard of the Rural Five-Guarantees Civil Affairs of 2015 Supporting and Service Organizations Anhui Province Opinions of Anhui Province for Guiding the Construction of Department of the Rural Five-Guarantees Supporting and Service Civil Affairs of 2015 Organizations Anhui Province Special Action Plan of Department of Civil Affairs of Anhui Department of Province on Solving Prominent Problems in Development of Civil Affairs of 2015 Aged-care Service Industry Anhui Province Measures of Anhui Province for Managing Fixed Subsidy Department of Fund of the Rural Five-Guarantees Supporting and Service Civil Affairs of 2015 Organizations Anhui Province Department of Plan of Anhui Province on Implementing Training to Workers Finance of 2015 in Aged-care Service Institutions Anhui Province and etc. Opinions of Anhui Provincial People's Government on Further People's Improving the System of Assisting and Supplying the People Government of 2016 Living in Extreme Poverty Anhui Province 46 Health and Family Opinions on Promoting Combination of Medical Care and Planning 2016 Aged-care Service Commission of Anhui Province and etc. Department of Special Action Plan of Anhui Province on Service Quality Civil Affairs of 2017 Construction of Nursing Home in 2017 Anhui Province Department of Circular on Taking Special Actions on Service Quality Civil Affairs of 2017 Construction of Nursing Home Anhui Province Subtotal of the 20 policy documents Opinions of Wuhu on Further Accelerating Development of the Wuhu Bureau 2010 Aged-care Service Industry of Civil Affairs Anqing Opinions of Anqing People's Government on Accelerating Municipal 2012 Development of the Aged-care Service Industry People's Government Suzhou Opinions of Suzhou People's Government on Accelerating Municipal Construction of the Aged-care service System of the Whole 2013 People's City Government Xuancheng Comprehensive Opinions of Xuancheng on Accelerating Development of the Municipal 2014 Aged-care Service Industry People's Government Wuhu Opinions of Wuhu People's Government on Accelerating Municipal 2015 Development of the Aged-care Service Industry People's Government Municipalities Anqing Several Policies of Anqing on Promoting Social Forces to Municipal 2016 Offer Basic Public Services in 2016 People's Government Lu An Bureau of Civil Measures of Lu An for Constructing Social Aged-care service Affairs, Lu An 2017 System Bureau of Finance Measures of Anqing for Managing the Rural Five-Guarantees Anqing Bureau 2016 Supporting and Service Organizations of Civil Affairs General Office Opinions of the General Office of Anqing Municipal People's of Anqing Government on Promoting Combination of Medical Care and Municipal 2016 Special Aged-care Service People's Government Special Action Plan of Department of Civil Affairs of Lu An Lu An Bureau on Improving the Guarantee Measures and Well Developing 2015 of Civil Affairs Aged-care Service Measures of Lu An for Operating and Maintaining the Lu An Bureau 2016 Five-guarantee Supporting Mechanism of Civil Affairs 47 Lu An Opinions of Anqing Municipal People's Government on Municipal 2016 Accelerating Development of the Aged-care Service Industry People's Government Measures of Suzhou for Constructing the Rural Suzhou Bureau 2010 Five-Guarantees Supporting and Service Organizations of Civil Affairs Opinions of Suzhou on Guiding Construction of High Standard Suzhou Bureau 2011 and Normative Rural Demonstration Nursing Home of Civil Affairs Wuhu Bureau of Civil Measures of Wuhu for Constructing Social Aged-care service Affairs, Wuhu 2015 System in 2015 Bureau of Finance Xuancheng Bureau of Civil Measures of Xuancheng for Constructing the Rural Affairs, Five-Guarantees Supporting and Service Organizations and the 2015 Xuancheng Nursing Home Bureau of Finance Xuancheng Bureau of Civil Measures of Xuancheng for Constructing Social Aged-care Affairs, 2016 service System in 2016 Xuancheng Bureau of Finance Measures of Suzhou for Implementing Evaluation on Suzhou Bureau 2016 Aged-care Service (trial) of Civil Affairs Xuancheng Bureau of Civil Measures of Xuancheng for Operating and Maintaining the Affairs, Five-guarantee Supporting Mechanism and Rural Nursing 2016 Xuancheng Home in 2016 Bureau of Finance Suzhou Bureau of Civil Measures of Suzhou for Constructing Social Aged-care service Affairs, 2017 System in 2017 Suzhou Bureau of Finance Xuancheng Bureau of Civil Measures of Xuancheng for Constructing Social Aged-care Affairs, 2017 service System in 2017 Xuancheng Bureau of Finance Wuhu Bureau of Civil Measures of Wuhu for Constructing Social Aged-care service Affairs, Wuhu 2017 System in 2017 Bureau of Finance Subtotal of the 23 policy documents Data sources: Official site of governments of various levels. 48 2.4.2 Specific policies of the project area on construction and management of diverse aged-care service system (taking Anqing for instance)11 Local governments of the project area have promulgated a series of specific policies or implementation rules to implement the policies of the State Council and ministries and commissions of the Central Government on construction and management of diverse aged-care service system12. Anqing has mainly promulgated and implemented the following policies on this regard since 2015: 1) Policies supporting social forces to offer aged-care service Subsidy for investment into aged-care service industry. For the aged-care service facility investment project in 2016 with fixed asset investment in that year (excluding the land cost) of more than Five million Yuan, one-time subsidy as per 10% of the investment will be given while the maximum subsidy will be One million Yuan. Subsidy for construction and operation of social capital invested aged-care service institutions 13 . The social capital invested aged-care service institutions permitted in 2016 (including those newly built, expanded and rebuilt in 2015 and 2016 and thereafter) can be offered corresponding subsidy for construction (establishment) and operation. Refer to Table 2-5 for the details. Table 2-5 Subsidy of Anqing for construction and operation of social capital invested aged-care service institutions in 2016 Subsidy for construction (establishment) Subsidy for operation Subsidy policy Subsidy Subsidy policy Subsidy Number of Subsidy for each conditions Self-care Annual subsidy conditions 11 This mainly refers to Several Policies of Anqing on Promoting Social Forces to Offer Basic Public Services in 2016. 12 Since the regional economic and social difference in China is big, policies formulated by the Central Government are often the basic principles, lines, guidelines or qualitative guiding opinions and local governments will promulgate some specific implementation plans and rules according to the local actual conditions so as to implement the policies of the Central Government. Since many of the policies of the central government on construction and management of diverse aged-care service system are long-term policies, local governments can only implement them gradually according to the actual needs and will not simultaneously advance them. Hence, local governments of the project area only formulated and carried out some implementation plans and rules on construction and management of diverse aged-care service system. 13 Namely the non-government sponsored aged-care service institutions. 49 beds bed ability of the for each person move-in elderly people can completely 1) Permitted in 2400 Yuan take care of 2016; 2) himself/herself occupancy rate of Below 300 2,000 Yuan 1) Permitted Moderate loss above 50%; 3) the in 2016; 2) of intelligence number of the normal 3600 Yuan and self-care elderly people operation of ability will be identified more than Moderate loss by the municipal one year and of intelligence civil affairs occupancy 4800 Yuan and self-care bureau and the More than rate of above ability subsidy will be 300 5000 Yuan 50% Severe loss of calculated (inclusive) intelligence according to the 7200 Yuan and self-care identified number. ability Subsidy for operation of home-based care service. For the community home-based aged-care service stations run by the enterprises or social organization upon bidding or entrustment of the county (municipal) or district level civil affairs department in 2016 and identified by the civil affairs department that they meet the service standard, each station will be given subsidy as per standard of annually 30,000 to 50,000 Yuan after one-year's normal operation. Subsidy for construction of comprehensive aged-care service information platform. For the social organization which invested to build comprehensive health service information platform integrating medical care, nursing, physical fitness and home-based care in 2016, one-time subsidy will be given as per 30% of the platform construction cost but will not be more than 500,000 Yuan. Subsidy for procurement of commercial pension insurance. If the social capital invested aged-care service institutions purchase general liability insurance for the aged living in the institution, the subsidy standard will be annually 20 Yuan per bed; if such institutions purchase accident insurance for them, the subsidy standard will be annually 80 Yuan per person14. 14 Anqing has explored the establishment of nursing insurance system for the destitute dependents (rural residents 50 Government procured service. If the social service institutions winning the bidding offer visiting service to the solitary or empty-nest elderly people, the government will procure the service as per the standard of monthly 50 Yuan/household15. Ability assessment of the aged. Assess the living activities, mental status, perception and communication and social involvement ability of the elderly people living in social capital invested aged-care service institutions, the elderly people with difficulties and enjoying the government procured service and the elderly people who have lost their only child as per the standard of annually 100 Yuan/person. 2) Policies supporting capacity building of basic aged-care service Subsidy for trainings to the newly recruited staffs. If offering skill trainings to the newly recruited staffs who have signed contract with term of more than six months, one-time subsidy as per the standard of 500 Yuan/person will be given to the training organization. Subsidy for trainings of improving skills of the old staffs. The workers in aged-care service industry who have obtained the national occupational qualification certificate for nursing staff will be given one-time subsidy of 1000 Yuan, 2000 Yuan and 3000 Yuan respectively. Subsidy for introduction of the elderly nursing staff. Each of the staffs who have obtained national occupational qualification certificate for intermediate nursing staff and national occupational qualification certificate for senior nursing staff and have signed labor contract of more than year with the social capital invested aged-care service institution will be given an one-time subsidy of 5,000 Yuan and 10,000 Yuan respectively. Each of the staffs who graduated from nursing major of universities and colleges and have signed labor contract of more than one year with the aged-care receiving five-guarantees and urban San Wu people in the city) since August 2014. As of September 2015, the insurance company has cumulatively received 440 claim cases and paid 306,800 Yuan. In December 2015, Anqing expanded the coverage of the insurance system and increased the insured object to 2,333 and premium standard to annually 190 Yuan/person. 70% (totally 310,289 Yuan) of the premium will be borne by the municipal level public welfare fund of lottery and 30% (totally 132,981) will be raised by the district-level government. 15 Anqing municipal government implemented the project of procuring service for elderly people of above 70 years old who have living difficulties and choose home-based care service from October 2014 to September 2015. For this, Anqing has paid 333,600 Yuan which served 278 people for more than 13,500 person-times. Anqing continued to implement such project from December 2015 to November 2016 and increase the subsidy standard to monthly 200 Yuan/person. The fund required will be borne by the municipal revenue and district revenue according to the proportion of 7:3. The specific implementing units are Anqing Gaopai Home-based Care Service Center and Anqing Boren Social Work Service Center. 51 service institution will be given an one-time subsidy of 3,000 Yuan. 2.5 Overview on poverty in the project area 2.5.1 Overview on urban and rural poverty in the project area The project area has relatively larger poor population16. The population was 1,624,000 in 2015, accounting for 52.6% of the poor population in Anhui province. The poverty rate (proportion of poor population to the total population) in project area is 7.01%, obviously higher than the average level (5.72%) of Anhui province. The poor population in the project area is mainly concentrated in Lu An, Suzhou and Anqing. In 2015, these three municipalities have poor population of altogether 1,527,000, accounting for 94% and 49.4% of the poor population in the project area and Anhui province respectively. The poverty rate in these three municipalities is up to 9.22%. Refer to Table 2-4 for details. Table 2-4 The poverty-stricken areas and poor population in the project area in 2015 Poor Poverty Region National level poverty-stricken counties population rate (10000) (%) Shou County, Jinzhai County, Huoqiu Lu An 69 11.95 County, Shucheng County, Yu'an District Xiao County, Si County, Dangshan County, Suzhou 36.6 6.60 Lingbi County Susong County, Qianshan County, Yuexi Anqing 47.1 8.99 county, Taihu County Wuhu / 7.3 2.00 Xuancheng / 2.4 0.93 Project 162.4 7.01 area Anhui 308.8 5.72 Province Another common indicator to weigh the poor population is the number of people 16 In China, poor population is concentrated in rural areas and the counted poor population only covers the rural residents. Standard to identify the rural poor residents is: the average net annual income was 2,300 Yuan in 2011 and about 2,800 Yuan in 2015. 52 receiving social relief (minimum living standard allowance for urban/rural residents). According to data of Ministry of Civil Affairs (Table 2-5), the number of urban residents of Anhui Province receiving minimum living standard allowance in the fourth quarter of 2016 was 545,865, including 28,850 San Wu people and 167,362 elderly people (above 65 years old), and the proportion of elderly people to the number of urban residents receiving minimum living standard allowance was 30.66%; the number of rural residents receiving minimum living standard allowance was 1,498,194, including 655,469 elderly people, and the proportion of elderly people to the number of rural residents receiving minimum living standard allowance is 43.75%. The project area has 193218 urban residents receiving minimum living standard allowance, accounting for 40.33% of that of Anhui Province. Of which 10529 are San Wu people and 54029 (namely 27.96% of them) are elderly people. 247688 rural residents in the project area receive minimum living standard allowance, accounting for 35.4% of that of Anhui Province, of which 193218 are elderly people, accounting for 40.99%. Table 2-5 Population receiving minimum living standard allowance in the project area in the fourth quarter of 2016 Rural areas Urban areas Proportion Proportion of elderly of elderly Number of people to Number of people to the people the people number of receiving number of receiving San Wu people Region minimum The aged people minimum The aged people receiving living receiving living minimum standard minimum standard living allowance living allowance standard standard allowance allowance (person) (person) % (person) (person) (person) % Lu An 162635 59482 36.57 48508 2938 9904 20.42 Suzhou 134616 76006 56.46 26962 156 5611 20.81 Anqing 158688 46113 29.06 41439 1025 9793 23.63 Wuhu 67569 27400 40.55 55118 5775 22544 40.9 53 Xuancheng 80703 38687 47.94 21191 635 6177 29.15 Project 604211 247688 40.99 193218 10529 54029 27.96 area Anhui 1498194 655469 43.75 545865 28850 167362 30.66 Province The data is obtained from website of the Ministry of Civil Affairs of PRC http://www.mca.gov.cn/article/sj/ 2.5.2 Existing poverty alleviation strategies in the project area 1) Rural poverty alleviation strategy In February 2017, Planning of Anhui Province on Poverty Alleviation during "13th Five-year Period" (hereinafter referred to as the Planning) was formally promulgated. The Planning points out that we should implement ten major poverty alleviation projects: poverty alleviation through industrial development, poverty alleviation through employment, poverty alleviation through relocation, poverty alleviation through ecological environment protection, poverty alleviation through intelligence, poverty alleviation through social security, poverty alleviation through development of health cause, poverty alleviation through infrastructure construction, poverty alleviation through financial support and poverty alleviation through social support. We should focus on poverty alleviation in the key areas (Dabie mountain area, North Anhui Region and old revolutionary base areas) and realize the poverty alleviation objectives comprehensively: all of the poor population identified as per the current standard are lifted from the poverty, all of the poor villages are stricken out of the list and all of the poor counties get rid of the poverty name. 2) Social security The social security system is the final guarantee to ensure that the poor and low-income groups can get the basic protection for survival. Currently, Anhui Province has basically established the social security system covering both urban and rural areas. This mainly includes pension insurance system for urban and rural residents, basic medical insurance system for urban residents, new cooperative medical insurance system in rural areas and the minimum living guarantee system for 54 urban and rural residents. In addition, the government has set up special fund to offer help to the poor and low-income groups. This includes relief for major diseases, relief for disasters, relief for the disabled, system to supply the elderly people receiving five-guarantees, system to supply the San Wu people, relief for vagrants and beggars, subsidy for house lease of low-income groups, fund to ensure safety of drinking water in rural areas and relief for the "left-behind" children. 2.5.3 Role of this project in poverty alleviation The elderly people accounts for a large proportion among the population living absolute poverty. Construction of comprehensive aged-care service system can directly alleviate the poverty. Local governments in the project area mainly adopt decentralized aged-care service mode (home-based aged-care) and centralized aged-care service mode (care of reception type institutions) to offer basic guarantee for the poor elderly people. The decentralized aged-care service mode will be the dominant mode. There are mainly two support means. The first is that the government supports the construction, improvement and operation of the government-sponsored aged-care service institutions. This mainly refers to that the government builds and improves the government-sponsored reception type aged-care service institutions, such as old people's home, nursing home and welfare home, pays basic salary to some workers and directly pays the subsidies for the received poor elderly people to the government-sponsored reception type aged-care service institutions according to the national or local standard. The second is that the government formulates and improves whole or part of the policies supporting the poor elderly people. The policies mainly are pension subsidy policies for the poor elderly people (including paying subsidies to poor elderly people who choose home-based care every year; paying various aged-care service cost to the reception type aged-care service institutions for poor elderly people who choose centralized care service according to their self-care ability); policies on service procurement of the government (the government pay a certain amount of money to the social capital invested aged-care service institutions and buys 55 cleaning, bathing, catering, aid in emergency and aid in seeking medical treatment and other service for the elderly people who choose home-based care service) and policies supporting social capital invested aged-care service institutions (policies on subsidizing the buildings construction and beds procurement of the rural reception type aged-care service institutions and one-time subsidy policy for reception of the poor elderly people and so on). This project involves all of the above mentioned aspects. Hence, implementation of this project will help Anhui Province and the project area realize the poverty alleviation objectives. Lu An and Suzhou are right the main municipalities in Dabie Mountain Area and North Anhui Region. In particular, Suzhou has 4 national level poor counties: Dangshan County, Xiao County, Lingbi County and Si County, and one provincial level poor district: Yongqiao District. The upgrading and transformation of rural nursing homes in Suzhou, a component of this project, will create employment opportunities and lighten the burden of rural low-income elderly people. This is obviously helpful for alleviating the absolute poverty in rural areas of Suzhou. Data of Table 2-4 can support this. The elderly people accounts for 56.46% of the rural residents receiving minimum living standard allowance in Suzhou. This proportion is the highest among the five municipalities in the project area and that of Dangshan County is even up to 75.61%. According to our survey, 45.83% of the elderly people who move in the rural aged-care service institutions are San Wu people, 4.17% of them are the disabled and semi-disabled elderly with dementia and 8.33% of them are low-income elderly people, making the total proportion be 58.33%. 3. Main social benefits brought by the project Through establishment and management of diverse aged-care service system, World Bank-financed Anhui Aged-care System Project will help Anhui Provincial People's Government enhance the ability to manage the diverse aged-care service system and enable the municipalities in the project area to improve its ability of community 56 service for the aged, expand the service scope and improve the service quality of urban and rural key aged-care service institutions in the project area. The profitability of the project will be affected by the development of future aged-care service market to a large extent and there are still some uncertainties about achieving the ideal income level. However, the project, a large construction project of public welfare infrastructures and government support system by procurement of service, will be helpful to relieving the practical problems brought by aging in Anhui Province, improving the aged-care service system and making Anhui Province be a demonstrate province in World Bank's implementation of aged-care service system construction in China. These great social benefits should not be overlooked. 3.1 The project implementation can create employment opportunities, especially the opportunities for the women Table 3-1 shows the service scale based on the project proposals and feasibility study reports of the municipalities and the estimated new employment opportunities according to the scale of 1:10-15. The data shows that the project will directly benefit more than 100,000 elderly people and will create employment opportunities for at least 7,220 people. It will employ nursing staff, management staff, medical staff, social workers, analysis and evaluation staff and manufacturing workers and so on. According to the traditional concept, aged-care is "serving" and not a "decent job" with low income, bad working environment and intensive workload. So it is not attractive in young people. Currently, the middle-aged and old-aged people, especially the rural low-income women, are the main workers in the aged-care service industry. This will not change fundamentally in the near future. Hence, a considerable amount of the 7,220 people will be middle-aged women. They are vulnerable groups in the society since they do not receive much education and are older. However, they can play their advantages of being hard-working, patient and caring in this industry. 57 Table 3-1 The number of people directly benefited by the project implementation and operation and the number of staffs and types of work to be newly added Number of the Employees to be Region Item people to be Type of the staffs recruited served Annually 8500 Care for the urban empty-nest 850 (based on the Social worker and nursing and altogether elderly people scale of 1:10) staff 42,500 Annually 5,000 person-times Ability/demand assessment system and altogether Analysis and evaluation staff of the aged above 65 years old 25,000 person-times Procurement of service items for 2,500 (based on Social worker and nursing the aged with economic 25,000 the scale of 1:10) staff difficulties Annually 2,000 person-times Respite care for the households Social worker and nursing and altogether 300 with disabled elderly people staff Lu An 10,000 person-times all-purpose card for aged-care 100,000 cards Producing staff service Fostering of social organizations 12,000 70 Professional teaching staff for provision of service to the aged person-times Upgrading and transformation 34 and serving 64 (calculated as of community the elderly Social worker or nursing staff, per 2 persons per home-based people in management staff station) aged-care community service station Social worker or nursing staff, Nursing center of the Hospital of 500 beds 400 management staff and medical Traditional Chinese Medicine staff Upgrading and transformation of Nursing staff and management Suzhou 35 175 rural and township nursing homes staff Visiting and catering service for 1300 (based on the Nursing staff, analysis and the urban empty-nest elderly 27,170 scale of about Anqing evaluation staff people 1:15) Ability assessment of the aged 120,098 Analysis and evaluation staff 58 Decentralized home-based care 56 (based on the Nursing staff and management 561 service for the five-guarantees scale of 1:10) staff Subject to the actual number Social worker, nursing staff Respite care of people who and management staff have signed the contract Community Social worker, nursing staff Other services 127 1200 home-based and management staff aged-care 40 (based on the Social worker and nursing Daycare center 200 beds service station scale of 1:5) staff Nursing home for the elderly Social worker, nursing staff, 250 (based on the people of First People’s Hospital 1,000 beds management staff and medical scale of 1:5) of Anqing staff Community-embedded care Social worker, nursing staff, 300 (based on the centers for disabled and 1,473 beds management staff and medical scale of 1:5) Wuhu semi-disabled elderly staff Smart health and aged-care service Technical staff, call center management center staff and management staff Xuanzhou District Social Welfare Social worker, nursing staff 400 beds 55 Home and management staff Xuancheng Ningguo Municipal Social Social worker, nursing staff 260 beds 10 Welfare Home and management staff Comprehensive aged-care service Serve the whole Technical staff and information system province management staff Assessing the aged for 30,000 Ability and demand assessment person-times Evaluation staff and 100 system of the aged and training up management staff Provincial to 1,000 level evaluation staffs Construction of the aged-care Serve the whole service standard system province Cumulatively All kinds of professional Training of professional talents in 150 (based on the train more than nursing teachers and aged-care service scale of 1:150) 15,100 staffs management staff Data sources: based on the project proposals, feasibility study report and field interview of various regions 59 3.2 The implementation of the project will change the traditional view on aged-care service & promote social transformation In traditional Chinese culture, "bringing up sons to support parents in their old age" roots in the minds of people from generation to generation, affecting their aged-care practice. With the deepening of urbanization and aging, this traditional concept is facing the dilemma of transformation. In the late 1970s, China's national development strategy had undergone a fundamental transformation, and the planned economy was transformed into a market economy. Under the market economy, individualization and atomization are obvious. The family planning policy rapidly changes the family structure, making the social flow rapidly accelerating. The urban and rural labor force goes out for employment, the traditional aged-care mode-cohabitation-begins to face the dilemma. In response to this change, the Chinese government began a series of reform on old-age security system. In 1991, the State Council issued the Decision on the Reform of the Pension Insurance System for Enterprise Employees, and proposed that the state, enterprises and individuals share the cost of pension insurance, and implement the social pooling and individual contribution mode; In 1995, the State Council issued the Notice on Deepening the Reform of the Pension Insurance System for Enterprise Employees, and promulgated the concrete implementation method of combining social pooling with individual contribution. In 1997, the State Council issued the Decision on Establishing a Unified Pension Insurance System for Enterprise Employees, formalized its payment rate and payment method, and extended the basic pension insurance system to all enterprises and their employees at the town-level. In 2009 and 2011, China has launched the rural-resident social pension insurance pilot and urban-resident social pension insurance pilot, both utilizing the new financing mode-social pooling and individual contribution. By 2015, the two pension insurance system have both achieved its full coverage. The previously established urban-employee pension insurance pushes China into the era with a well-founded 60 pension system, and "society" plays a more and more importance role in pension practice. The project aims to support the establishment of a diversified aged-care service system in Anhui Province, and is sure to transform the concept on aged care and its mode and to provide facilities and talents for this kind of service. 3.3 The implementation of the project will improve the overall management and service capacity of Anhui provincial government on the diversified aged-care service system The component 1 includes four aspects: provincial-level comprehensive aged-care service information system, the ability assessment and needs assessment system for the elderly, the standard aged-care service system, and the aged-care service professional personnel training system. 1) The construction of comprehensive aged-care service information system can improve the efficiency of government management, optimize the allocation of aged-care resources, and provide a wide range of effective services Information-based aged-care service is supported by the Internet, Internet of Things, modern communications, computer networks, and the aged-care service industry and intelligent control technology. It provides safe and efficient means for release of aged-care service information, timely provision of aged-care service and management of the aged-care institutions, and represents the development trend of advanced aged-care service mode. The information-based aged-care service in Anhui Province is home-based aged-care service information platform and mainly supported by enterprises. Such system lacks self-management. The current problem includes: existence of information island, lack of information-based development of the aged-care institution, low coverage of information-based aged-care services and the inadequate content of aged-care services. 61 The implementation of the project will establish a comprehensive information system on aged-care service at provincial level and have its management function. The system integrates the information on aged-care service from institutions, communities, and homes, and helps provide guidance on planning, monitoring and governing of aged-care services for the government; It will help deepen awareness and promote the development of aged-care service industry. It will also help aged-care institutions timely and effectively complete the work such as qualification, rank-auditing, annual inspection, application for government subsidies and agency recommendation; and will help the public better understand and choose aged-care service providers, modes and articles for the aged use. Provincial Project Management Office (PPMO): its first function is to determine the eligibility of the elderly for claiming the subsidies and the reasonable subsidizing standard. Currently, the government mainly bases on whether the economic source is single to determine the object receiving the subsidies and only the elderly receiving the minimum living standard allowance can get the subsidies. The physical conditions of the disabled and semi-disabled elderly are not taken into account. Meanwhile, all elderly people who are eligible for receiving the subsidies were treated all the same and no different measures depending on the specific conditions are taken. Upon formation of the system, the provincial level elderly people information database, especially the information database based on the ability and demands evaluation of the elderly people, will be established and thus provide data basis for offering aged-care service and releasing aged-care subsidies to the disabled and semi-disabled elderly. Its second function is to establish provincial level aged-care service information platform, offering information connection for aged-care service and solving the problems of asymmetric supply-demand information. One of the important functions of the platform is to offer aged-care service information for the public. Upon formation of the system, list of aged-care institutions, notice and announcement, activities for the elderly, protection of the elderly’s rights, aged-care maps, courses for the elderly, products for the elderly, healthy-keeping, dynamics on aged-care service, age-related laws and regulations, consulting and complaints and so on will be released on the platform, realizing that the elderly people can receive real-time, diversified, personalized and comprehensive aged-care service without the necessity to step out of their homes. 62 2) The reunification of the ability and demands evaluation system of the elderly can ensure the full use of the limited aged-care service resources, which is of great significance to the government in formulating the aged-care regulations and the provision of appropriate aged-care service for the elderly. The accurate ability and demands evaluation of the elderly can enable the government and regulators to make more scientific policies and plans and can enable the communities and aged-care institutions to more reasonably develop the service items, arrange appropriate nursing staffs and thus efficiently offer suitable service to the elderly people. In recent years, Anhui Province attaches great importance to the work of the ability and demands evaluation for the aged, and has issued a series of documents and plans. Some cities have implemented the work and certain achievements have been made, but there are still a series of problems to be solved. First of all, there is no unified demands evaluation system for the relevant aged-care service, making it unable to realize effective link-up of aged-care related regulations. In other words, high administrative costs for the aged lead to low efficiency in providing services. Second, the ability and demands evaluation of the aged in each region is mainly carried out by the staff from the local aged-care service information center. There is lack of professionals such as doctors, therapists, nurses, social workers, and psychological counselors. Thirdly, the evaluation results should have been used to help the aged in choosing aged-care services, subsidy release, auxiliary equipment, barrier-free transformation, and applications of long-term care insurance. It should also have been used to assist the government in allocating resources and making decisions. However, such information is not shared within the system, resulting in repeated assessment and waste of resources. The project will introduce professionals and assessment agencies to establish a unified system for ability and demands evaluation of the aged in Anhui Province. The information obtained from ability and demands evaluation should be shared within the organizations to help make scientific regulations for public subsidies and identify the priority in receiving aged care service. It will help improve the efficiency of resource 63 sharing, and make rational allocation of limited aged-care resources possible. Ultimately, the aged will be able to enjoy a reasonable and appropriate service through the scientific assessment information. During the implementation period, the number of trainee in performing evaluation work will be 1,000, and the aged being evaluated will reach 30,000 person-times. Tens of thousands of the aged will directly benefit from the project, bringing in good social benefits. 3) The perfection of the standard of aged-care service system will help construct a good aged-care service market Currently, the supply structure in aged care is not reasonable, the market potential is not fully released, and the quality of service needs to be improved. Thus, Anhui Province issued a number of local standards for aged-care service to regulate the management & supply of aged-care institutions, and planning and construction of relevant facilities. However, the ability and demands evaluation system of the aged, the assurance system of aged-care service, and the evaluation and improvement system of the aged-care service needs to be standardized to improve the quality of aged-care service and supervision work. The aged-care service standards and unified quality & evaluation system include: basic standards, service skills standards, service management standards, home-based aged-care service standards, community aged-care service standards. Strengthening of market norms will be conducive to the standardization and aged-care service, so that the service can be carried out lawfully in an organized way. The steady and healthy development of the whole aged-care service market requires the establishment of fair and open market rules. 4) The professional training system for the aged-care service can effectively cultivate professional talents and upgrade the service level of the industry The nursing competence of aged-care service practitioners is a basic guarantee for the aged to maintain their health. In Anhui Province, a large group of the aged need aged-care services, but the number of qualified personnel of the industry is rare. Most of the practitioners lack basic care knowledge, experience and skills. Professionals are 64 badly needed in aged-care institutions, such as doctors, nurses, dietitians, therapists, psychological counselors, and social workers. In addition, many of the aged cannot take care of themselves, making the nursing work burdensome. Due to traditional beliefs, those engaged in aged-care services are mostly middle-aged (40-50) women. The low level of education & overall quality seriously constrains the rapid development of the aged-care service industry in Anhui Province. The project provides training courses on aged-care service for nursing staff and managers (short-term, on-the-job training, or 4-year academic education) , and provides management capacity training for staff from government departments. According to the preliminary plan, it will provides 7 training courses, offering training for a total of 15,000 front-line practitioners, professional & technical personnel and volunteers. Through outsourcing, service-purchasing and other forms, we will invite reputable training institutions to provide the training courses. Besides, we will actively work with the higher education institutions to carry out university-level training courses for aged-care services. In addition, the project will help create new jobs, effectively promote the development of the aged-care industry and promote social and economic development in Anhui Province. 3.4 The implementation of the project will greatly enhance the capacity of home-based aged-care service in project area Home-based aged-care service within the community is community-based and treats the family as its core. Professional service personnel should be offered to solve the problem of the aged in daily life, providing services such as life care, health care, and spiritual comfort. Being offered the door-to-door service and day care, the aged can get socialized aged-care services within the community, saving manpower and material resources both for individuals and the society. Anhui Province attaches great importance to the development of community home-based aged-care service. Within the project area, new communities are basically provided with community day care center (station) or elderly activities center. For 65 instance, 170 urban and rural communities in Anqing City have built 151 home-based aged-care service stations. Governments at all levels have issued and implemented a number of regulations to support the establishment and development of home-based aged-care services. However, there are still a series of problems in its rapid development: For example: insufficient facilities of home-based aged-care service, government procurement is not enough; supervision and regulation mechanism is not perfect; and capacity of aged-care institutions is not strong, which is unable to meet the basic needs of the elderly. The implementation of this project will greatly enhance the capacity of home-based aged-care service in the following areas. 1) Revitalize stock of resources & increase effective supply Survey in Anqing, Lu An and Wuhu shows that many of the community home-based aged-care service stations are equipped with relevant facilities and areas. However, due to constraints in staff and operating mechanism, the facilities and areas have not been fully utilized. The project will reconstruct the 161 home-based aged-care service stations in Anqing City & Lu An City, covering all the communities within the project area. Reconstruction and decoration should be carried out in accordance with the function of each zone. Meanwhile, supporting service facilities should also be constructed. After the implementation of the project, professional operators should be invited (public construction & private operation mode) to manage the aged-care service stations. 2) Increase government procurement of home-based aged-care services Government procurement of the services should be implemented in both Anqing and Lu An city. As early as 2014-2015, the two cities have already purchased home-based aged-care services. However, the service scope is limited, mainly focusing on serving the aged supported by the government. E.g.: As to Anqing City, from the end of 2014, the city started to purchase such services in a pilot area, covering only 200 elderly people concentrated in Yingjiang District. The scope of Lu An is larger, but investment from the government is only 3 million Yuan. As to this project, it sees a huge improvement both in the scale of services and service content. The purchased services of Anqing city: (1) visiting services for empty-nest elderly; 66 (2) elderly ability evaluation project; (3) home-based aged-care service for the aged enjoying five-guarantees; (4) meal-delivery service for empty-nest elderly; (5) respite care service; (6) other services. Purchased services & an assessment service of Lu An City: (1) care services for urban empty-nest elderly; (2) capacity / requirement assessment service for those over the age of 65; (3) purchased services for the aged; (4) respite care services; (5) all-purpose card for aged-care service; (6) training social-organization for aged-care services; (7) Mid-term and post-project evaluations. The number of elderly directly benefiting from the services listed above is more than 10 million in the 2 cities. 3) Mechanisms and methods to improve supervision and regulation As to current community home-based aged-care services, the government acts as a participant, a supervisor and a system maker. But the government lacks mature, effective, scientific and complete benefit evaluation system and implementation methods. Meanwhile, the approval process is also mostly implemented by the government, and the supervision cost is too high. The lack of regulatory mechanisms reduces the quality of home-based aged-care services, and satisfaction and happiness of the elderly. The project will improve the supervision and regulation mechanism. In addition to the establishment of monitoring and evaluation team from relevant government departments, we will also seek technical assistance, invite advisory team, and establish third-party monitoring mechanisms for guaranteeing measures, training programs, inspection quality, and assurance (resettlement and environmental) supervision. The project will also see innovative measures in supervision and regulation approach. For example, Lu An city will issue all-purpose card to service consumer to facilitate the process in providing subsidies. Service staff will provide home-based aged-care services in a door-to-door mode. After the end of the service, the service consumer can pay the cost of service via the all-purpose card. Through relevant technical support, we can save the corresponding consumption records (including service content, the number of services, service time, service costs, etc.). Through the 67 consumption data, we can check on the services provided by the aged-care institutes. Relevant server, database and operating system will be built to help the government find out the size of home-based aged-care services, and access the details of the service at any time to facilitate the supervision and subsidy-grant process to enterprises. Anqing Civil Affairs Bureau proposed to establish a service regulatory information platform to solve this problem, which is consistent with the idea of construction of a provincial-level aged-care information system. The method is to make the service and service personnel equipped with intelligent equipment, connected to the service regulatory information platform, where the government can monitor the entire service process in real time. Director Lu from Anqing Civil Affairs Bureau: Why build this information platform? With this platform, we can regulate the service staff's services & his/her movement path. For example, I can locate every service staff and see his/her service time & contents without any third-party platform. We do not have to get the above information through the grassroots community, and that is why we determined to build this information platform. 4) Introduction of powerful social organizations for aged-care The project area is currently under the pilot project of community home-based aged-care service in a public construction and private operation mode. For example, Anqing City introduced Changsha Wanzhonghe Community Service Network Company, which sets up an aged-care service center in LashuYuan community of Daguan District. It is planned to build other aged-care service networks, and the embedded-type aged-care service network within the community (long-term reception of the elderly) is included in the scope of the project. Wuhu City introduced state-owned Anhui Haoyan Aged-care Service Investment Management Company, which created two models in aged-care service center of Dafu Community and TingYuan Community. As to Lu An City, it has Xinde Home-Based Aged-Care Service Center and Anhui Dongfangjuren Health Management Co., Ltd. and so on. These pilot projects have achieved good results and the stock of resources have been fully utilized, and has been highly praised by the elderly. 68 An elderly from Aged-Care Service Center of Anfeng Community in Lu An city (Anhui Dongfangjuren Health Management Co., Ltd.) “Services from aged-care institution are normal and authentic and I am satisfied. I come every day to stay for most of the day, taking some fitness and entertainment activities (playing ball, chess, erhu fiddle and so on)â€?. The aged-care service station will be under a management mode which is "public construction and private operation". That is: Well-chosen public institutions should be responsible for post-project operation, and the government will purchase aged-care services. To be specific, after the completion of the project, public institutions with administrative functions should be chosen to operate the center and the government of the city should act as its administrative agency; the Embedded-Type Disabled/Semi-isabled Aged-care Center should be under the management of Anhui Haoyan Aged-Care Service Investment Management Co., Ltd. 5) Develop embedded-type community home-based care service market Although home-based care currently receives government attention, the market sees its potential, and social organizations are eager to enter that market. However, the actual economic benefits are not ideal, how to solve this issue? To solve this problem, many places has come up with embedded-type home-based aged-care. Director Pan of Lu An Civil Affairs Bureau: From my point of view, the most important thing currently is to set up the structure. The government should support the elderly in real need, and offer nurses, administrators, aged-care institutions to ensure the elderly can get a professional aged-care service. Second, embedded & small-scale aged-care institutions should be set up at community and sub-district level. I mean to change the view of two types of people: the first is those who are reluctant to live in nursing homes. So we now want to change the view that sending the elderly to the nursing home is against filial piety. To live in nursing home is not to reduce living standards. Most of my acquaintances live in nursing homes, so we now need to develop an embedded-type aged-care center. On the one hand, we need to change the view of the elderly; on the other hand, we should make the service really convenient to the public. This is similar to nursery school. There is nursery school in community, so why there shouldn't be a nursing home in community? We have entered into the aging society. Director Pan suggests embedded-type home-based care from the perspective of changing the view of the public, while president Liu of the Aged-Care Association of Lu An city made a cost calculation of the project. He believes that the home-based 69 aged-care station should be admitted to receive the elderly needing long-term care, in particular, those who cannot take care of themselves. Liu, President of Lu An Aged-Care Association: Why can't we find the market? To make money and find the rigid demand is the key. Loans have to be repaid, but the government's procurement and subsidies should be larger. Downstairs of community service station must be the activity center. The upstairs is the aged-care service institutions, because the biggest profit point is the care costs of those who cannot take care of themselves. The current standard is 1480 Yuan / month for elderly with self-care skills; half disabled: 2000 Yuan / month; whole disabled: 2800 Yuan / month. The cost consists of: food costs, bed fees, nursing fees, utilities, etc.. Water & electricity and food costs are rigid with generally no profit. The profit mainly lies in the bed fee and nursing costs. The number of elderly with self-care skills accounts for 1/4: with little profit margins & care costs, the profit mainly lies in the bed fee, which is 100-200 Yuan. But things are different when we consider those who cannot take care of themselves. Nursing fee and the bed fee means a profit of at least 500 Yuan/month. The Yinghe Apartment for the Aged lies within the city, and is close to the community. There are 500 beds available. If there are 200 who cannot take care of themselves, a month's profit will reach 100,000 Yuan. Even without government subsidies, we can make ends meet. Aged-Care Service Center of LashuYuan Community of Daguan District in Anqing provides 24-hour care, day care and on-site service, of which the latter two are free services. The head of the center told us that although there are only 3 elderly people enjoying the 24-hour care, but it is the center's main profit point. This project (including seven community-level embedded-type disabled/semi-disabled aged-care service center and one intelligent health and aged-care service management center) will not only alleviate the problem that the aged faced in health and daily life, but will also improve the sustainability of the project on economic prospect. In terms of functionality, the full care and semi-care services of the full-care service center of the Anqing Home-Based Care Station should also be considered as a community-based embedded disability and semi-disabled service station for the elderly (200 beds should be provided, tentatively). 70 3.5 The implementation of the project will enhance capabilities of professional care services and management within the project area Sub-project includes: the expansion of 2 health-care institutions, a new construction area of 132,690.2m², and 1,900 new beds; Reconstruction and expansion of 2 welfare homes, a new construction area of 28,554m², and 660 new beds, of which welfare home of Xuanzhou District will be relocated, with a planned total land area of 40,000m² (about 60 mu); Upgrading and renovation of 35 rural nursing homes, with a total construction area of 32,850m² and 1060 new beds. 1) The integrated medical and aged-care institutions The project will build two integrated medical and aged-care institutions: First People’s Hospital of Anqing and Traditional Chinese Hospital of Lu An. From the view of function, the Yinhu Aged Nursing Hospital in "Haoyan-CaihongYuan" in Wuhu should also be listed as integrated medical and aged-care institutions. Anqing City, as a pilot city, has 1 urban area, 4 districts, 6 counties under its jurisdiction. Its goal is: to the end of 2017, each county (city) will build 2-3 standard demonstration sites for integrated medical and aged-care institutions; by 2020, a comprehensive medical & aged-care integrated service network with appropriate function & scale should be built within urban and rural areas. To achieve the goal of 2017, Anqing City need to build at least 22 integrated medical and aged-care institutions. However, as of the end of 2016, Anqing City has built 5 integrated medical and aged-care institutions. That is to say, it still needs to build 17 integrated medical and aged-care institutions In medical security, Lu An City has no health care oriented aged-care institutions. Only some of the hospital have rehabilitation department, and these are not dedicated rehabilitation department for treating age-related diseases. Many aged-care institutions has few medical staff ( with low professional skill). Some are not equipped with emergency medical equipment for carrying out emergency treatment of 71 common diseases of the aged. In summary, in Anqing City and Lu An City, the establishment of integrated medical and aged-care institutions can help alleviate the shortage of health care oriented aged-care institutions. In order to get the attitude and needs of the elderly and their families on the construction of integrated medical and aged-care institutions, the investigators conducted questionnaire survey in Traditional Chinese Hospital of Lu An and two communities (One is near the Traditional Chinese Hospital of Lu An: Remin Village Community, located at Zhongshi Street, Liuan District; one is far from the Traditional Chinese Hospital of Lu An: Qing'an Community, located at Gulou Street, Yu'an District ) from June 28 to 30, 2017. The survey show that the number of empty-nest elderly and elderly living alone is large, accounting for 47.4%, which is greater than the number of the elderly living with their children (45.76%). When these elderly people's self-care skills naturally decline, some of them should rely on the services provided by aged-care institution —— During our interviews, some elderly people and their families said they had this plan in the future. The expectation on aged-care mode of the elderly people is consistent with the current mode, with the main changes as following: the number of elderly hoping to live in aged-care institution accounted for 13.56%, indicating that their concept on aged-care is changing, and needs on social aged-care continue to grow. The relationship between elderly's expectations on aged-care mode and income: 85% of those expecting to live in aged-care institutions have low and middle income (monthly income no more than 3,000 Yuan). There are a variety of reasons that the aged don't want to live in the aged-care institution. Traditional concept of enjoying their later years with the family ranks first: 34.04% of the elderly believe "living together with family members is very good. “That the aged-care institution charges too highâ€? ranks the second (25.53%). In addition, there are other reasons: poor aged-care services, living conditions, limitation of freedom, and lack of medical rehabilitation services. It can be seen that most of the elderly (about 66%) who do not want to spend their later years in aged-care institution 72 are mainly dissatisfaction with its facilities, conditions, services, and charges. The newly-built aged-care institution integrating medical and aged-care function is featured with advanced equipment, high service quality, and reasonable price. Therefore, it is able to meet the requirement of the elderly in the project area. "If the multi-functional building of Chinese medicine hospital is built, are you willing to live there?" 27.1% clearly says "no" as "it is unaffordable". Among them, 78.57% are low income groups (monthly income less than 3,000 Yuan). Most of the elderly have expressed their willingness, of which 20.3% of the elderly said, " Yes, very willing to live there & higher charges does not matter."27.1% of the elderly said, " Yes, as long we can afford to the charges". 23.7% of the elderly said, " No, unless get ill and doesn't have anybody to take care of me." Consistent with this, more than 86% of the elderly support the construction project of Traditional Chinese Hospital of Lu An financed by the World Bank. Among the project supporters, 61.4% and 56.8% of the elderly believe the project can "reduce the burden on children" and "solve the problem of seeing a doctor", respectively. Thus, it can be seen that: whether it is statistical information or on-site survey data, the construction of integrated medical and aged-care institutions will enhance the capacity of professional care services and management within the project area, thus meeting the growing demand of the elderly on the institutional/social aged-care service and health care. 2) Rural township-level nursing home China's rural aged-care service institutions are mainly publicly- owned nursing home, and those admitted into the nursing home are mainly "the elderly enjoying the five guarantees" The case is the same in Suzhou City. All the nursing home are publicly owned, and there is a small amount of public-owned nursing home run by private enterprises. As to Suzhou City, it has 166 public-owned aged-care service institutions, which are mainly rural nursing homes. According to the needs of each county, we choose 35 nursing homes as the pilot for the World Bank project. These nursing homes have 73 higher occupancy rate and are in good operation conditions. However, as they are built long time ago, the facilities and equipment have aged and needs to be upgraded. Through the upgrading project, we will speed up transformation of rural nursing home to rural aged-care service center. We will seek innovation in the construction and operation mode of nursing homes to enhance its capacity to support the elderly enjoying five guarantees. Besides, we will provide aged-care service to the elderly of other groups to alleviate contradiction of supply and demand in aged-care service of the aged population in rural area. Number of nursing homes selected in each area: Dangshan County: 5; Xiao County: 6; Yongqiao District: 11; Lingbi County: 8; Si County: 5. The implementation of this project will enhance the service capacity of nursing homes in the following areas: First, improve the infrastructure & update the old equipment. From the survey of six nursing homes, it can be seen that the infrastructure is imperfect and the equipment is poor. The survey also shows that more than 50% believe that recreational facilities, beds, living facilities and safety facilities need to be improved; about 30% think that rehabilitation care equipment, newspapers, magazines and books also need to be improved. Among the elderly, 63% said that the area that most needed to be improved is the "living facilities" in the nursing home, while 50% the area that most needed to be improved is "rehabilitation and entertainment services". Take Zhaozhuang Nursing Home in Dangshan County as an example: Its floor area is 10 mu. In 2004, it is changed from the township government to nursing homes. Currently, there are 8 staff, and 75 elderly enjoying five guarantees. Lack of infrastructure: There is neither TV nor bathroom, with a small amount of very-old furniture. No shower facilities and air conditioning. The house that they live in is the dilapidated houses build from 1980's (see Figure 1-2). Cui, director of the nursing home: The nursing home is formerly known as Zhao Village Nursing Home, using houses build from 1980s. It is now called Zhao Village Aged-Care Service Center, covering an area of 10 mu. There are 42 dilapidated rooms, of which 6 rooms fall, and there are 36 rooms in use. In 2016, the Security Bureau, Civil Affairs Bureau, and the fire brigade 74 carried out a survey and concluded that these are uninhabitable rooms which expose cracks everywhere in rain. These rooms are defined as dilapidated rooms. There is no office or restaurant. So we are happy to know that there is a World Bank financed project in upgrading the nursing home. The survey show that the reason most of the elderly who have not chosen the nursing home are due to the poor service and facilities of the nursing home. For example, many of the respondents Zhenbei Village of Beiyangzhai are unsatisfied with the service quality, living standards of the Xingfu Nursing Home there. Therefore, only 30% of elderly people want to live the nursing home. The nursing home in Fengmiao Town & Yangtuan Town are provided with better facilities and high-level management. Therefore, there is high occupancy rate and the elderly need to wait in line for admission into the nursing home. As a result, the World Bank's project will improve the facilities, strengthen management and improve the level of service of nursing home to win the support of the majority of the elderly and their families. Second, the project will improve the working environment and salary of staff. There are serious shortage of professional staff in nursing homes. The rate of the number of people & management staff in city's nursing home is 10:1. In 2016, as the increase of the number of disability, the rate is changed into 6:1. But due to particularity of the work of nursing homes, managers do not have holidays and weekends. Bitter work leads to frequently resignation, thus affecting the day-to-day management of nursing homes. The result is the nursing homes only cares about the accommodation of the elderly. There is no entertainment, health care, and rehabilitation, let alone long-term care. Even in Town Center Nursing Home of Qi County in Yongqiao District with better facilities, the elderly there can only rely on self-management, self-service, and mutual help. The survey also indicated that 56% of the employees holds that the current staff is in shortage. More than 90% of the staff holds that the current work intensity is too high, and 88% of the staff holds that the staff we need is those with compassion, not those educated and professional (major). 75 The reason for this situation is that wages are too low. The salary of nursing staff in Suzhou (minimum wage-city area: 1250 Yuan / person / month; county area: 1150 Yuan / person / month) —— unified adjust to 1300 Yuan / person / month, and no social security are provided. Subsidies for those taking care of 6 disabled elderly is 500 Yuan, but it is very hard for a nursing staff to do that. Imperfect infrastructure, obsolete equipment and serious shortage of professional staff results in high bed vacancy & low elderly occupancy rate. From the survey of the 6 nursing homes, we find that there are many vacant beds. The highest is town nursing home in Qi County, Yongqiao District, reaching 62%. The lowest is the nursing home in Fengmiao, with no vacancy rate. According to the information provided by the Civil Affairs Bureau of Suzhou City, the vacancy rate of the beds in the township-level nursing home of Qi County is about 50%. If not considering the elderly not enjoying the five guarantees, this proportion is realistic. Table 3-1 Basic information of nursing home Total number of Elderly elderly Elderly Those Those not enjoying with enjoying with Location Staff Number five five Occupancy enjoying Vacancy (person) of bed disability disability rate(%) the five rate(%) guarantees or guarantees or (person) in the guarantees dementia dementia (person) (person) town (person) (person) Hongxin Nursing Home, 17 (all Beiyang 15 100 39 219 17.81 elderly 44 Village, with Yongqiao dementia ) District Town Nursing Home, Qi More than County, 100 38 3 100 20 38 0 62 Yongqiao District Nursing Home of Zhaotun Town, 8 75 17 266 30 28.2 0 Dangshan County Nursing Home of Pingshan Town, Si 7 90 76 11 395 Dozens 19.24 0 27 County Huangkou Nursing Home, 7 130 80 5 508 35 15.75 22 22 Xiao County Fengmiao Nursing Home, 20 220 160 36 458 70 34.93 60 0 Lingbi County 76 The high vacancy rate means low occupancy rate (the ratio of the total number of elderly enjoying five guarantees in town and that of those living in town nursing home). The lowest is Huangkou Nursing Home in Xiao County, which is only 15.75%; the highest is Town Nursing Home of Qi County, Yongqiao District, which is 38%. Low occupancy rate means that most of the elderly enjoying five guarantees live with their families. In particular, a considerable number of elderly with disability and dementia does not live in the nursing home. It can be seen that there is a certain gap between the government requirement that the elderly enjoying five guarantees should live in nursing home and the reality. In order to improve the salary of staff and the operation of nursing homes, Suzhou City began to promote the transformation and upgrading of nursing homes for the elderly. Nursing homes can now use its existing vacant beds to accommodate the elderly not enjoying the five guarantees, and then used the money earned to help increase the salary of staff. We surveyed six nursing homes, and there are three expressing the desire to admit the elderly not enjoying the five guarantees. There are already three nursing homes providing compensable service for elderly not enjoying the five guarantees. For example, the Hongxin Nursing Home begins to join Taiwan Anxin Aged-Care Chain Organizations, becoming the first aged-care service institution under public-private joint management to accept 17 elderly with disability and dementia. Fengmiao Nursing Home in Lingbi County are entirely public. There are 60 elderly people, with a zero bed vacancy rate. The occupancy rate reaches 35%, which is a successful example. Director of Hongxin Nursing Home, Beiyang Village, Yongqiao District, Suzhou City: We would like to add more than 50 beds. We want to centralize those elderly from everywhere, and Beiyang Village only has one nursing home for the elderly. The capital income: government subsidy is more than two hundred thousand Yuan a year; and the revenue from the elderly not enjoying the five guarantees is about two hundred thousand Yuan. The food of those enjoying the five guarantees and those not enjoying the five guarantees are not the same: they eat separately. If admitting elderly not enjoying the five guarantees, nursing homes need to give rental fees to the finance sector of the village before being returned to nursing home. Charges for elderly not enjoying the five guarantees are about 2,500 Yuan, and charges for those with self-care skills are 77 about 1000-1500 Yuan. Full care of the elderly means a lot of service, so the charges are high. For us, we hope to admit more elderly with full care. Liu, vice director of Fengmiao Nursing Home in Lingbi County: currently there are a total of 160 beds, and now they are all full with elderly enjoying the five guarantees. Besides, there are more than 60 beds provided for elderly not enjoying the five guarantees. That is a total of 220 (elderly not enjoying the five guarantees and elderly enjoying five guarantees are separately counted). The ratio of those who can take care of themselves and those who cannot take care of themselves is 1:1 (elderly not enjoying five guarantees). Since 2014, the charge rate is: those with self-care skills, 800 Yuan / month; those with no self-care skills, 1,200 Yuan / month; for groups from 800 Yuan / month, we earn 200-300 Yuan. For groups from 1, 200 Yuan / month, we earn a little more. The number of nursing personnel and the number of elderly not enjoying the five guarantees is 1:6. There are 20 nursing staff who is responsible for the care of elderly enjoying five guarantees. The profit distribution of the nursing home: the rent revenue (15,000 Yuan per year) is used as staff salaries (200 Yuan per staff per month; another 100 Yuan/month is used for performance appraisal, which is to increase the salary of staff). Management staff are under unified management of the director. Whether it is from our survey, or from the introduction of the Civil Affairs Bureau in Suzhou, we can conclude that receiving the elderly not enjoying the five guarantees can help improve the salary of service personnel, improve the quality of nursing homes, and reduce the vacancy rate. The implementation of the World Bank project will greatly improve the hardware and software conditions of the nursing home, and it will certainly accelerate the speed of receiving the elderly not enjoying the five guarantees in the community. 3) Urban social welfare home According to the feasibility study report, the current population of the main city zone of Xuanzhou is 363,000. The aged population is 71,000, of which there are about 4,100 who is disabled or semi-disabled. Besides, the empty-nest elderly, with a population of 39,500, accounts for more than 55%. According to the construction plan of 45 beds per thousand elderly people in Anhui Province, 3,195 beds are needed in the main urban area of Xuanzhou. However, there are only 380 aged-care beds. That is to say, to meet the requirement, Xuanzhou need to build 2,815 aged-care beds. As of the end of 2015, the total population of Ningguo City is 383,000. The number of those who is 60 years old and above is 65,000. The ratio of aged population is as high as 16.9%. Among the aged population, the number of those with disability and 78 dementia is about 7,000. It is estimated that by 2020, the aged population of Ningguo City will reach 85,000, accounting for more than 20% of the total population. According to the construction plan (45 beds per thousand elderly) of Anhui Province, Ningguo City needs 3,825 beds in 2020. However, the total of existing aged-care beds in Ningguo City is just 2,960, there are 565 more needed. The project plans to use the existing land in the Ningguo City to build a social welfare service center. Construction contents: construction of aged-care service center; construction of "longevity paradise" cultural activities center; and upgrading of ancillary facilities and supporting facilities. The total construction area is 9,054 m², and 260 new beds. In Xuanzhou District, the existing welfare homes will be relocated and reconstructed. Living, medical rehabilitation and other equipment will be purchased; construction of supporting roads and parking area, green area, outdoor playground, and ancillary facilities like water supply and drainage systems, fire systems, and electrical systems. The total construction area is 19,500 m², and 400 new beds. The project will not only help improve the standards of existing facilities and services, but also help increase the number of beds to admit more elderly not enjoying the five guarantees. 4. Stakeholder analysis Stakeholders of this project refer to interest groups or institutions concerned with the project design, construction and operation. In order to conduct the stakeholder analysis, the primary task is to identify those stakeholders, their major concerns and influences of this project on them. The major task of conducting the stakeholder analysis at the preparation and implementation stage of this project is to determine whether interest demands of various stakeholders have been included into project decisions. As interest demands of some groups (especially those immigrants) may be weakened by the Project Implementation Unit (PIU), the development right of displaced person may not be protected appropriately. As a result, the social equity and justice may be damaged and 79 the wealth gap may be widened, which is adverse to the balanced and coordinated development of the society. 4.1 Identification of stakeholders Stakeholders of the project are those individuals or groups affecting or affected by the achievement of project goals. Stakeholders can be divided into primary stakeholders and secondary stakeholders, depending on their impacts on project decisions. For example, governmental supervision departments, social organizations and service providers are major stakeholders of the component 1. In this project, the aged and their family members are ultimate beneficiaries while they pose no huge influences on the content and decision makings of component 1. Therefore, the aged and their family members are only secondary stakeholders. By analyzing the project nature and social impact, conducting field investigations and organizing interviews with relevant organizations, primary and secondary stakeholders have been identified for various components. Results are shown in Table 4-1. 80 Table 4-1 Stakeholders, benefits and damages caused by the project Project name Stakeholders Benefits Damages Primary stakeholders: Governmental supervision The project can help the government to grasp dynamic information and enhance the departments, service providers (social supervision and guidance efficiency after it is completed. It will help deepen the Construction of the organizations or people occupied in aged-care understanding of the aged-care industry and promote the industrial development. It will comprehensive aged-care services ); also help to show the conditions of aged-care institutions fairly and objectively, and None service information Secondary stakeholders: People receiving assist aged-care institutions to complete the qualification accreditation, grading, annual system relevant services (the aged), potential buyers of inspection, application of government subsidies and institutional marketing and services (family members or guardians of the promotion timely and effectively. In addition, it will help the public to understand and aged) choose the aged-care institution, service mode or aged-care product more effectively. Primary stakeholders: Governmental supervision departments, service providers (social After the project is completed, the governmental supervision departments can be Construction of the organizations or people occupied in aged-care enabled to formulate relevant policies and plans more scientifically, customized ability and demands services); services will be provided by the community and aged-care institution for the aged more None Component 1 evaluation system for the Secondary stakeholders: People receiving reasonably, and appropriate nursing personnel will be allocated to provide suitable aged relevant services (the aged), potential buyers of services for the aged efficiently. Ultimately, the aged will be able to enjoy reasonable services (family members or guardians of the and appropriate services provided basing on scientific assessment results. aged) Primary stakeholders: Governmental supervision Construction of the Major benefits include the established aged-care service system and the improved departments, service providers (social standard aged-care service standard across the whole province, which will lay the foundation for the None organizations or people occupied in aged-care service system standardization of aged-care services. services ); Primary stakeholders: Service providers (social The ability of managerial personnel and nursing personnel of aged-care institutions, and Training of professional organizations or people occupied in aged-care managerial personnel from governmental supervision departments will be improved. talents involved in services, training institutions), governmental None The four-year specialty of aged-care service will be established in relevant colleges and aged-care services supervision departments, teachers and students universities to enroll students. from relevant colleges and universities. Primary stakeholders: People receiving relevant services (the aged) and service providers (social On one hand, the diet and daily life of the aged will be provided at home, and the organizations or people occupied in aged-care community service provider can offer essential services which cannot be provided by Environmental services) of 34 communities in Lu An; the family members, thus saving lots of labor and material resources. impacts during Home-based care service Secondary stakeholders: Residents and cadres of On the other hand, service providers are also provided with the site and market for constructions Component 2 station relevant communities, and governmental business operations. supervision departments Primary stakeholders: People receiving relevant On one hand, the diet and daily life of the aged will be provided at home and the Environmental services (the aged) and service providers (social community service provider can offer essential services which cannot be provided by impacts during 81 Project name Stakeholders Benefits Damages organizations or people occupied in aged-care the family members, thus saving lots of labor and material resources. constructions services) of 127 communities in Anqing; On the other hand, service providers are also provided with the site and market for Secondary stakeholders: Residents and cadres of business operations. Therefore, the providers of community services for the aged are relevant communities, and governmental also provided with the site and market share of business operations. supervision departments Ability/demand assessment for the aged and all-purpose card for aged-care service will Old people aged over 65 years old be provided. Urban empty-nest elderly, the aged losing the only child and solitary Archives for the aged, regular family visits, and senior activity centers will be provided. elderly The elderly with financial difficulties Daily care, medical assistance and health care services will be provided. Lu An Disabled elderly and their family None City Respite care will be provided. members Service institutions will be provided with the fund, market and professionally trained Service providers talents. The training program will provide 15,000 people occupied in aged-care services with professional trainings (4,000 people per year). Potential buyers of services (the aged Those potential buyers will obtain abovementioned convenient aged-care services at a or their family members) reasonable price. Government funded Old people aged over 60 years old Capability assessment for the aged aged-care services Urban empty-nest elderly, the aged The aged will be provided with various services including the establishment of personal losing the only child and solitary file, regular visits, and effective interactions with their children who are not around. elderly Dispersedly supported aged people who are guaranteed with food, The personnel file will be established, and life assistance, spiritual consolation, medical clothing, medical care, housing and Anqing care, life caring and funeral services will be provided for those aged people. burial expenses in the municipal None City district Disabled elderly and their family Respite care will be provided. members Service providers will be provided with the fund, market and professionally trained Service providers talents. Potential buyers of services (the aged Those potential buyers will obtain abovementioned convenient aged-care services at a or their family members) reasonable price. Embedded care center for Disabled and semi-disabled elderly living in 7 After the project is completed, aged-care service providers will be provided with the disabled and community-embedded aged-care centers in aged-care market within the project area and 1473 beds for disabled and semi-disabled None semi-disabled elderly Wuhu City, and the service provider (Wuhu elderly. A considerable number of disabled and semi-disabled elderly will be provided 82 Project name Stakeholders Benefits Damages Jinhui Health Industry Investment Co., Ltd.) with relevant services. After the project is completed, the hospital will be provided with the fully equipped Environmental First People’s Hospital of Anqing, and disabled nursing home with advanced equipment. Therefore, the service scope will be enlarged impacts during and semi-disabled elderly served by this hospital and excellent services will be provided to eligible disabled and semi-disabled elderly. constructions Integrated medical and aged-care institutions After the project is completed, the hospital will be provided with the multi-functional Traditional Chinese Hospital of Lu An, and Environmental medical building fully equipped with advanced equipment. Therefore, the service scope disabled and semi-disabled elderly served by this impacts during will be enlarged and excellent services will be provided to eligible disabled and hospital constructions semi-disabled elderly. Transitional arrangement for Component 3 Primary stakeholders: Welfare homes in After the project is completed, the welfare homes in Ningguo City will be provided with existing residents Ningguo City and existing residents therein; new service centers and cultural activities centers, which will promote the quality of in those welfare Secondary stakeholders: Aged people planning services provided to existing residents therein. 260 beds will be provided additionally to homes, and to move to the welfare home admit more aged people not enjoying five guarantees. environmental impacts during constructions Transitional arrangement for Welfare homes in urban existing residents cities in those welfare Primary stakeholders: Welfare homes in homes, land Xuanzhou District and existing residents therein, After the project is completed, the welfare homes in Xuanzhou District will be provided acquisitions and and involuntary immigrants incurred by with fully equipped new buildings with advanced equipment, which will promote the house demolitions constructions of new welfare homes; quality of services provided to existing residents therein. 400 beds will be provided required for Secondary stakeholders: Aged people planning additionally to admit more aged people not enjoying five guarantees. constructions of to move to the welfare home new facilities, and environmental impacts during constructions 35 rural nursing homes in the project area and The equipment will be upgraded, and nursing homes will be reconstructed and Transitional existing residents therein. expanded, which will improve the quality of services provided to existing residents arrangements for Rural nursing homes Secondary stakeholders: Aged people planning therein. 1,060 beds will be provided additionally to admit more aged people not existing residents to move to the welfare home within the project enjoying five guarantees while wishing to move to nursing homes within the project in those welfare area area. homes, and 83 Project name Stakeholders Benefits Damages environmental impacts during constructions. Project management, The management ability of various project management offices (PMO) and Component 4 monitoring & evaluation, Governmental supervision departments None implementation units will be improved. and capacity building 84 As shown in Table 4-1, complex stakeholders are involved in this project and they can be broadly categorized into the following categories: Governmental supervision departments: This type of stakeholders includes project supervision departments, administrative departments and implementation departments. 7 administrative units and 17 implementation units of this project are shown in Table 4-2. Table 4-2 Administrative and implementation departments of the project Administrative department Implementation department PMO of Department of Civil Affairs 1 Department of Civil Affairs of Anhui Province of Anhui Province PMO of Anqing Bureau of Civil Anqing Bureau of Civil Affairs 2 Affairs First People’s Hospital of Anqing PMO of Lu An Bureau of Civil Lu An Bureau of Civil Affairs 3 Affairs Traditional Chinese Hospital of Lu An Suzhou Bureau of Civil Affairs Civil Affairs Bureau of Yongqiao District PMO of Suzhou Bureau of Civil Civil Affairs Bureau of Lingbi County 4 Affairs Civil Affairs Bureau of Dangshan County Civil Affairs Bureau of Xiao County Civil Affairs Bureau of Si County PMO of Wuhu Bureau of Civil Wuhu Bureau of Civil Affairs 5 Affairs Wuhu Jinhui Health Industry Investment Co., Ltd. Xuanzhou District Civil Affairs Bureau in PMO of Xuanzhou District Civil 6 Xuancheng City Affairs Bureau in Xuancheng City Xuanzhou District Social Welfare Home PMO of Ningguo Civil Affairs Ningguo Civil Affairs Bureau in Xuancheng City 7 Bureau in Xuancheng City Ningguo Municipal Social Welfare Home Project supervision departments refer to relevant departments exercising the supervision power in accordance with relevant national and local procedures and regulations, including the civil affairs department (bureau), finance department (bureau), development and reform commission, department (bureau) of human resources and social security, health and family planning commission, and department (bureau) of environmental protection. Service providers: Service providers include social organizations and people occupied in aged-care services. Generally, social organizations refer to 85 enterprises, governments, schools, hospitals and social groups providing aged-care services. Social organizations act as operating agencies in this project. The home-based aged-care service station will be managed under the mode of “public construction and private operationâ€? where post-project operations will be conducted by well-chosen operators. To be more specific, government funded aged-care services will be operated by administrative organs responsible for aged-care services and public institutions subject to the Civil Servant Law and empowered with administrative management functions. The Integrated medical and aged-care institutions will be operated and managed by hospitals after the completion. Community-embedded care centers for disabled and semi-disabled elderly will be managed and operated by Anhui Haoyan Aged-care Investment & Management Company Limited. After the completion of Xuancheng Welfare Home, the operation mode of “public construction and private operationâ€? is proposed to be adopted. Various types of specialized and non-profit social organizations will be delegated to manage and operate the welfare home. Ningguo Municipal Social Welfare Home will be operated and managed by itself after the expansion is completed. Upgraded, reconstructed and expanded rural nursing homes will be operated by their original organizations. People occupied in aged-care services: People occupied in aged-care services is a joint name of groups providing various aged-care services for the aged, including the nursing personnel, management personnel, professional service assurance personnel and volunteers. People occupied in aged-care services can refer to different groups, depending on types of institutions where they are employed. In hospitals, they can be doctors, rehabilitation physicians, nurses, nursing workers, logistical personnel, management personnel and medical technicians. In social welfare homes and nursing homes in both urban and rural areas, they can be nursing workers, medical workers, cooks, drivers, maintenance personnel and directors. In community aged-care service stations and embedded care centers for disabled and semi-disabled elderly, they can be more diversified. In addition to nursing personnel and professional personnel, social workers offering door-to-door special services (e.g. the psychologist/comforter, health worker and nutritionist) and community workers allocated by the government (e.g. the full-time aged-care assistant and full-time working personnel in charge of 86 aged-care services in the community) are also included. The aged and their family members: This group can be divided into two categories, including those who have received aged-care services and those who have not. They can also be categorized into potential buyers of aged-care services and aged people waiting to move to aged-care institutions. Residents and cadres of relevant communities in the project area: currently, many community home-based aged-care service centers are managed by the director of community residence committee or secretary of the CPC branch. The staff of community home-based aged-care service are mainly unemployed people or people from other places, have overall low quality and poor professional skills and do not receive relevant professional education or training on aged-care service knowledge and hence do not have the qualification of nursing staff for aged-care service. Involuntary resettlement: As the relocation and rebuilding of Xuanzhou District Welfare Home involve land acquisitions and house demolitions, the World Bank’s OP4.12 policy needs to be implemented and reports on the resettlement action plan need to be prepared. Therefore, interest demands and influences posed by this project on relevant displaced person will be separately discussed in the Resettlement Action Plan. 4.2. Interest demands of primary stakeholders in this project 4.2.1 Administrative and implementation departments of the project—civil affairs departments at various levels The civil affairs department has various functions, including researching, formulating and implementing the development planning for the local social welfare business, as well as formulating and implementing rules and regulations protecting the interest and right of special groups including the aged, parentless children and the disabled. What’s more, the civil affairs department also needs to implement management regulations stipulated by the government for various welfare institutions, as well as to 87 construct and manage social welfare homes, urban welfare institutions for the aged and rural institutions supporting persons with five guarantees. Therefore, the Department of Civil Affairs of Anhui Province and civil affairs bureaus of the other five prefectures are stakeholders closely related to this project. They are very supportive of this project and they hope that the project can be implemented as soon as possible. Demands of those stakeholders are as follows: 1) Full support from supervisors and full cooperation from various stakeholders are required to accomplish objectives and tasks of the World Bank project at different stages and to improve the capability and image of the administrative organization; 2) It is expected that the construction and management of the diversified aged-care service system can be promoted by this project. Social forces are also expected to be absorbed into the aged-care sector to promote the comprehensive development of the aged-care service sector in Anhui Province; 3) It is expected that the aged-care service market can be cultivated with the help of this project, and the competition mechanism of the aged-care market can be improved; 4) It is hoped that demonstrations can be developed to explore the suitable development mode of aged-care service for Anhui Province by accumulating experiences from the implementation of the World Bank project. PPMO: The main project objective is to support the establishment and management of diversified aged-care service system of Anhui Province and formation of aged-care service system covering both urban and rural areas with Anhui characteristics and reasonable layout, appropriate scale and improved functions, home-based aged-care as the basis, social aged-care as the support and institutional aged-care as the supplement. In light of the project contents, we think that the project will promote the improvement of the aged-care service system of Anhui Province and the cities and counties: first, improving the management ability of aged-care service system. The four provincial level components are mainly designed with aim at setting up and improving the management ability of diversified aged-care service system and will be implemented in such four aspects as information-based aged-care service, demands evaluation, standard aged-care service system and personnel trainings which all focus on the basic needs of aged-care service industry management. Second, focusing on provision and management of home-based aged-care service. The construction of home-based aged-care service stations and implementation of government-purchased service in Anqing and Lu An and construction of home-based aged-care service chain stations in Wuhu all focus on improving the facilities of home-based aged-care service, further exploring the specifications for standardizing and managing the home-based 88 aged-care service facilities; the government-purchased home-based aged-care service focuses on exploring the establishment of government purchase mode for the home-based aged-care service with Anhui characteristics. Third, improving the ability to serve the disabled and semi-disabled elderly. The social public welfare homes and the integrated medical and aged-care institutions in Anqing and Lu An all aim to serve the disabled and semi-disabled elderly and will play the demonstration role in improving the nursing ability and quality. Lu An Bureau of Civil Affairs: Currently, the most important task is to develop the framework for this project. The government should hold the bottom line of aged-care services, provide nurses and aged-care service institutions, and make professional aged-care service institutions available for the aged in demand. Secondly, embedded and small aged-care service institutions need to be developed in sub-district communities to change the unwillingness of aged people to move into nursing institutions. Thirdly, the home-based care should be developed and various socialized services (including the meal delivery, collective catering service, cleaning service and electromechanical maintenance) should be provided to the aged by professional institutions. What we need to do is to improve weak links to meet needs of the social life. As the World Bank loan has a long length of maturity and low interest rate, it is very suitable for the aged-care service sector. At present, the budget for aged-care services are restricted to financial budgets of previous years, and thus it is really difficult to increase the investment hugely for one time. Currently, the education sector, employment and social security sector, and the medical sector are top three sectors with heaviest investments. Investments into the aged-care sector have been ignored by the government for a long time. It is barely possible for the government to double investments into aged-care services. However, the World Bank project can help us to solve the financial problem and increase investments into aged-care services for one time. Even though investments will be ended after five years, the project will be continued in the 6th year, which will push the government to increase rather than decrease the investment. For example, as some projects have been implemented, subsequent investments cannot be terminated because we have invested tens of millions of funds into this project. As a matter of fact, the government cannot reduce investments if we want to upgrade the project to a new level. Anqing Bureau of Civil Affairs: The government hopes to promote the development of the aged-care sector by utilizing social forces. The State Council has promulgated the No. 91 official document not long ago and policies therein can be replicated in Anqing. The health management of the aged is tightly connected with aged-care services purchased by the government. Why is the governmental funded aged-care service applied as a World Bank project? The main reason lies in the limited financial resource of the government. As a matter of fact, only over 200 aged people with financial difficulties are guaranteed by the government while over 40000 aged people are living with low incomes. There are many difficulties in providing subsidies for aged people with financial difficulties. The aged-care market needs to be cultivated firstly and more social capitals need to be absorbed if the government wants to provide government funded services for more aged people with low incomes. Wuhu Bureau of Civil Affairs: We hope to utilize funds of the World Bank to promote the development of home-based care services. Management regulations and experiences of the World 89 Bank can promote the standardization of the aged-care service, which can further facilitate the development of home and community-based aged care services in a chain pattern across the whole province. At present, the profit of home-based care cannot be guaranteed yet. Governmental guarantees need to be provided to expand organizational aged-care services to surrounding communities. 4.2.2 Supervising and directing departments—other relevant government departments Although this project is mainly implemented, organized and managed by the civil affairs department, other related departments are also involved tightly. For example, the monitoring & evaluation team and the steering committee are constituted by members from the development and reform commission, health and family planning commission, human resources and social security department, educational department, land and resources department, housing and urban-rural development department, the office of the committee on aging services and social organizations such as the aged-care association. Among those departments, the National Health and Family Planning Commission is directly connected to the integration of medical and aged-care service. The Notice Forwarded by the General Office of the State Council about Guiding Opinions of the National Health and Family Planning Commission on Promoting the Integration of Medical and Aged-care Services has specified objectives for the integration of medical and aged-care services and ascertained responsibilities of those relevant departments. Details are as follows: “By 2017, the policy system, standard regulations and management systems should be preliminarily established for the integrated medical and aged-care service, and the professional training system for talents related to integrated medical and aged-care services should be developed basically to meet needs; Qualified and competent medical institutions or aged-care service institutions integrating medical and aged-care service functions (hereinafter referred to as integrated medical and aged-care institutions) should be established, and the ability of basic medical institutions in providing door-to-door services for 90 home-based aged people should be improved gradually; Green channels for convenient services such as the registration and medical consultation should be provided by over 80% medical institutions for the aged; it is expected that over 50% aged-care service institutions can provide medical services for the aged therein in different ways to improve the accessibility of the aged to health and aged-care services significantly. By 2020, the mechanism and system of policies and regulations suitable for national conditions should be established basically for integrated medical and aged-care services. Medical and aged-care resources should be shared in an organized manner, and the comprehensive and continuous integrated medical and aged-care service network with suitable size and reasonable functions should be developed basically to cover both urban and rural areas. The green channel providing convenient services such as the registration and medical consultation for the aged should be made available by all medical institutions. All aged-care service institutions should be capable of providing medical services for the aged therein, and health care and aged-care needs of aged people should be met basically.â€? On one hand, those relevant departments are involved into the supervision, direction, assistance and service for the implementation of this project. On the other hand, the outcome of the implemented project is directly related to political achievements of the government and relevant departments. Therefore, they are very supportive of this project and they hope that the following objectives can be achieved: 1) The aged-care service sector within the project area can be improved to promote the transformation of the economic structure and to facilitate the economic development; 2) The social governance can be promoted, the political stability can be achieved, and the image of the government can be improved with the help of this project; 3) The inclusive social development can be facilitated by the implementation of this project. 4.2.3 People occupied in aged-care services In general, those stakeholders hope that their services can be recognized by the aged and the society on one hand. On the other hand, they hope for increased income, 91 improved working environment, alleviated work intensity and more learning and improvement opportunities. 4.2.4 The aged and their family members Aged people are ultimately and directly benefited by this project. Aged people require for high-quality services and good living environment at reasonable prices. However, demands, physical conditions and economic conditions of different aged people are diversified, which results in different interest demands towards this project. The survey shows that disabled and mentally handicapped aged people who are unable to take care of themselves pay more attention to the residential environment and hardware facilities. They are pressed for door-to-door medical services, aged-service hotline, emergency assistance, emergency call equipment and mental consolation services. Aged people who are able to take care of themselves have more diversified demands and they are highly demanding about the indoor residential environment and surrounding environment. They hope that more convenient medical services can be provided and more entertainment and rehabilitation facilities can be established in their communities or aged-care service institutions. They also expect for enriched learning and artistic activities, enlarged activity space and improved environment. Interest demands of the aged and their families are highly consistent. 4.2.5 Various social organizations providing aged-care services Social organizations providing aged-care services can be divided into the reception type aged-care service institutions (e.g. the old people’s home, nursing home and welfare home), community and home-based aged care institutions, and various aged-care assessment institutions and educational institutions. In addition, some social charity organizations and social work institutions also provide some aged-care services. Relevant services in this project, including the civil works, equipment procurement, decoration works and government purchase, will be open to the society for public 92 bidding before the implementation. Many competitive aged-care service institutions will be attracted into the bidding process. However, the aged-care service sector has not been fully developed and the operating mechanism has not been standardized currently, creating difficulties for various potential contractors and restricting the development of a diversified and comprehensive aged-care service system. This project aims to promote and develop a comprehensive aged-care service market to facilitate the maturity of the aged-care service sector gradually. This project will also bring about development opportunities for aged-care service institutions. They can accumulate relevant experiences, acquire the market and thus gain further development step by step with the help of this project. Therefore, they are very supportive of this project. Demands from aged-care service institutions are as follows: 1) To create a fair, just and open bidding mechanism to enable them to participate into the project fairly; 2) To implement this project successfully as soon as possible, to provide favorable conditions in terms of funds, sites and policies, and to enlarge the aged-care market in order to reduce costs to the largest extent and make profits as early as possible; 3) To learn advanced foreign aged-care theories, management methods and experiences from this project to enhance their strengths. 4.2.6 Residents and cadres of relevant communities The establishment, reconstruction and expansion of standardized community-based aged-care service stations and the reconstruction of community-embedded care centers for disabled and semi-disabled elderly require relevant communities to provide unoccupied houses for the implementation of this project. Therefore, residents and working personnel of those communities will become stakeholders. They hope that those unoccupied houses can be fully utilized while avoiding adverse influences on original community activities at the same time. Table 4-3 Analysis of primary stakeholders and their interest demands Stakeholders Interest demands 1) Full support from supervisors and full cooperation from Civil affairs departments various stakeholders are required to accomplish objectives 93 and tasks of the World Bank project at different stages and to improve the capability and image of the administrative organization; 2) It is expected that the construction and management of the diversified aged-care service system can be promoted by this project. Social forces are also expected to be absorbed into the aged-care sector to promote the comprehensive development of the aged-care service sector in Anhui Province; 3) It is expected that the aged-care service market can be cultivated with the help of this project, and the competition mechanism of the aged-care market can be improved; 4) It is hoped that demonstrations can be developed to explore the suitable development mode of aged-care service for Anhui Province by accumulating experiences from the implementation of the World Bank project. 1) To get their services recognized by aged people and the society; People occupied in aged-care 2) To be provided with increased income, improved working services environment and alleviated work intensity; 3) To be offered with more learning and improvement opportunities. 1) High-quality services; The aged and their family 2) Good living environment; members 3) Reasonable prices. 1) To create a fair, just and open bidding mechanism to enable them to participate into the project fairly; 2) To implement this project successfully as soon as possible, to provide favorable conditions in terms of funds, sites and Social organizations providing policies, and to enlarge the aged-care market in order to aged-care services reduce costs to the largest extent and make profits as early as possible; 3) To learn advanced foreign aged-care theories, management methods and experiences from this project to enhance their strengths. Residents and cadres of relevant 1) To ensure that their own interests are not impaired; communities 2) To make full use of resources. 1) To improve the aged-care service sector, to promote the transformation of the economic structure, and to facilitate the economic development; Other government departments 2) To promote the social governance, to achieve the political concerned with aged-care stability, and to improve the image of the government with the services help of this project; 3) To facilitate the inclusive social development by implementing this project. 94 4.3 Benefits, benefited and damaged groups in this project Basing on the social impact analysis and stakeholder analysis of this project (especially the Table 3-1 and Table 4-1), benefits, benefited areas and groups, as well as damages and damaged groups can be identified. 4.3.1 Component 1--Comprehensive supporting capability of the provincial aged-care service Component 1 consists of 4 sub-projects of which primary stakeholders, benefits, benefited areas and benefited groups are diverse to some extent. 1) Sub-project 1: Comprehensive aged-care service information system Primary stakeholders include governmental supervision departments and social organizations providing aged-care services. Benefits are as follows: It can help the government to grasp dynamic information and enhance the supervision and guidance efficiency after the completion of the project. It will help deepen the understanding of the aged-care industry and promote the industrial development at the same time. It will also help to show conditions of aged-care institutions fairly and objectively, and assist aged-care institutions to complete the qualification accreditation, grading, annual inspection, application of government subsidies, and institutional marketing and promotion timely and effectively. In addition, it will help the public to understand and choose the aged-care institution, service mode or aged-care product more effectively. Benefited area and groups include the aged and their family members across the whole province. 2) Sub-project 2: Demand and ability evaluation system for the aged Primary stakeholders include governmental supervision departments and social organizations providing aged-care services. After the project is completed, relevant policies and plans can be formulated by governmental supervision departments more scientifically, customized services can be provided by the community aged-care institutions for the aged more reasonably, and appropriate nursing personnel can be 95 allocated to provide suitable services for the aged efficiently. Ultimately, the aged will be able to enjoy reasonable and appropriate services provided basing on scientific assessment results. Benefited area and groups include the aged and their family members across the whole province. To be more specific, 30,000 aged people will be assessed and 1,000 appraisers will be trained within the implementation period of this project. 100 jobs will be created, too. 3) Sub-project 3: Construction of standardized aged-care service system Primary stakeholders include governmental supervision departments and social organizations providing aged-care services. Major benefits include the established aged-care service system and the improved service standard across the whole province, which will lay the foundation for the standardization of aged-care services. 4) Sub-project 4: Training program for professional talents providing aged-care services Primary stakeholders include governmental supervision departments, social organizations providing aged-care services, relevant colleges and universities and training institutions. Benefits include the enhanced ability of nursing personnel and management personnel from aged-care institutions and civil affairs departments, and the establishment of the aged-care education system in higher educational institutions. Relevant colleges and universities across the whole province will be benefited. This project will also benefit many people directly. To be more specific, over 15,000 persons occupied in aged-care services, 525 management personnel from civil affairs departments and 500 undergraduate students will be trained and educated within the implementation period of this project. 150 employment opportunities will be created, too. 4.3.2 Component 2—Community home-based aged-care service Primary stakeholders include various aged people and their family members receiving aged-care services within the project area and the service provider (the operating agency of sub-project 2). Benefits of this project are as follows: the empty-nest elderly, aged people losing the only child, the solitary elderly, aged people 96 with financial difficulties, the oldest-old, disabled and semi-disabled elderly, aged people or community residents with incomes and in need of home-based aged-care services in urban areas will be provided with various reasonable and suitable services within the project area. Service providers will also be benefited in terms of governmental funds and market shares during the process of providing services. Over 100000 aged people and some of their family members in Lu An, Anqing and Wuhu will be directly benefited by the home-based aged-care service. Various employment opportunities will be generated for over 7,000 people as a consequence of such service (refer to Table 3-1 for details). 4.3.3 Component 3—Professional nursing service and management The Integrated medical and aged-care institutions: Major benefits are as follows: After the project is completed, the Traditional Chinese Hospital of Lu An and First People’s Hospital of Anqing will be enabled to integrate their own medical resources to provide basic services such as the daily care, health care, medical service and terminal care. Resources will be shared and various advantages will be complemented to achieve developments which are different from ordinary old people’s homes. It is expected that the aged will be looked after properly and sick people will be treated appropriately to relieve sons and daughters from anxieties and worries about their old parents. Benefited area and groups include all disabled and semi-disabled elderly served by this hospital. What’s more, the aged will be directly benefited by 1500 beds, including 1000 beds in Anqing and 500 beds in Lu An. In addition, many job opportunities will be created at the same time (refer to Table 3-1 for details). Welfare homes in urban cities: Two welfare institutions in Ningguo City and Xuanzhou District and existing residents therein, as well as farmers affected by the land acquisition and house demolition required for the reconstruction of the social welfare home in Xuanzhou District are primary stakeholders. Major benefits of this project are as follows: After the project is completed, the welfare home in Ningguo City will be equipped with new service centers and cultural activities centers for the aged, which will promote the quality of services provided for existing residents 97 therein. 260 beds will be provided additionally to admit more aged people not enjoying the five guarantees. What’s more, the welfare home in Xuanzhou District will be provided with new buildings fully equipped with advanced equipment, which will promote the quality of services provided to existing residents therein. In addition, 400 beds will be provided additionally to admit more aged people not enjoying the five guarantees. Noteworthy is that job opportunities will be newly created for 65 people. Township level nursing homes: 35 nursing homes in Suzhou and existing residents therein are primary stakeholders. Major benefits are as follows: Equipment will be upgraded and buildings will be reconstructed and expanded, which will improve the quality of services provided to existing residents therein. 1060 beds will be provided additionally to admit more aged people who wish to move to nursing homes while not enjoying the five guarantees. 4.3.4 Component 4--Project management, monitoring & evaluation, and capacity building Governmental supervision departments of various levels, especially those PMOs, are primary stakeholders. The implementation of the project will improve the management ability of PMOs and reduce the working load of relevant working personnel. 4.3.5 Major damaged groups 1) Land-acquired villagers As lands of some farmers will be acquired in order to relocate and reconstruct the Xuanzhou District Social Welfare Home, those farmers will lose means of production to some extent. However, as the quantity of acquired lands is relatively small when being compared with the amount of lands owned by each household, such adverse influence is largely limited. Therefore, the livelihood of those affected villagers can be restored quickly with the help of appropriate resettlement compensations. 2) Families whose houses are demolished 98 In order to relocate and reconstruct Xuanzhou District Social Welfare Home, houses of 6 peasant households need to be demolished. Therefore, resettlement houses need to be constructed for those families. The normal life of those families will be affected, too. 3) People occupied in aged-care services, aged people and workers affected by constructions According to the environmental impact assessment report, unsafe hidden dangers may be caused by this project, including toxic and harmful materials and damages incurred by construction operations such as the dust, noise, dumped soil and discarded slags. Most constructions are carried out within aged-care institutions such as the Suzhou Nursing home, Ningguo Municipal Social Welfare Home, and community-based aged care service stations in Anqing and Lu An City. Therefore, construction workers, aged people and working personnel in aged-care institutions will be affected if appropriate measures are not taken. Detailed influences are as follows: Firstly, if the noise level generated by constructions remains at over 80dB (A) for a long time, people around will be troubled by various degrees of hearing disturbance. What’s more, the production efficiency of workers will be reduced and accidents may be induced. The elderly will be seriously affected and other symptoms may be induced, too. Secondly, dusts will be generated out of constructions. Large amounts of dusts will adhere to the respiratory tract and thus induce various diseases. Thirdly, hidden dangers such as objects falling from high altitudes, object strikes, electric shocks and mechanical injuries may be caused by the work conducted high above the ground and operations of professional equipment during the construction. Fourthly, weak fire safety awareness, improperly equipped firefighting facilities or neglectful inspections of firefighting facilities will cause malfunctions of fire protection installations when unforeseen circumstances are incurred, which may cause casualties. Fifthly, buildings with inappropriate lightning protection and grounding facilities may be struck by the lightning, which may cause fires and even casualties. 99 4) Aged people requiring interim transitions during the project implementation Various aged-care institutions have formulated interim transition plans in order to reduce influences brought by constructions carried out within aged-care institutions. Consequentially, short-term disturbances will be generated for some aged people during the transition period. 5. The impact of the project on aged-care service workers 5.1 Basic conditions of aged-care service workers Owing to the lack of statistics on the aged-care service workers, we cannot grasp the overall situation of them in the whole project area. Therefore, this part mainly refers to the results of discussion and questionnaire survey on 24 aged-care service institutions (including 10 adoptive aged-care service institutions and 14 residential community-based or home-based aged-care service centers/stations) in 15 counties in the project area by social assessment group from March 1, 2017 to March 17, 2017.â‘  Among them, 158 workers of various aged-care service institutions are investigated in questionnaire (administrative staff, logistics staff, nursing staff, etc.). According to the service area and the main service content, the aged-care service institutions surveyed can be broadly divided into three categories: Urban residential community-based and home-based aged-care service institutions (48 people are interviewed), urban reception type aged-care service institutions (46 people are interviewed), and township reception type aged-care service institutions (64 people are interviewed). The units from different regions have certain representativeness. Unless otherwise stated, the chart data are from the survey results of the social assessment group. â‘ The respondents of discussions and interview surveys are officials of civil affairs department in the project area, and investors and workers of the aged-care service institutions. The sample obtained by the questionnaire may have a certain deviation from the project area, but the information obtained from other channels (discussion and literature) shows that the deviation is within a reasonable range. 100 5.1.1 Gender and age 1) Gender Because of the particularity of service objects and service content, women are more suitable for providing aged-care service, so the workers of various aged-care service institutions are mainly female. According to the survey, the average proportion of female workers in the aged-care service sector in the project area is 64.56%. Among them, the proportion of female workers in urban residential community-based and home-based aged-care service institutions is the highest, 70.83%; the proportion of female workers in urban adoptive aged-care service institutions is the lowest, 56.52%. The details are shown in Table 5-1. Table 5-1 Gender Structure of Workers in Different Types of Aged-care Service Institutions Unit: % Types of aged-care service institutions Urban residential Urban Township community-based adoptive reception type Average and home-based aged-care aged-care rate aged-care service service service institutions institutions institutions Male 29.17 43.48 34.38 35.44 Gender Female 70.83 56.52 65.63 64.56 Total 100.00 100.00 100.00 100.00 2) Age Influenced by the employment concept, work nature and income, few young people are willing to engage in aged-care service (especially nursing work); so the workers in aged-care service institutions are of high age, especially the township reception type aged-care service institutions with a large outflow of young and middle-aged labor force. The survey shows that among workers in aged-care service institutions in the project area, the youngest is 22 years old, the oldest is 79 years old, and the most of them are 48 years old; the average age of the workers is 45.77 years old, and the average age of male and female workers is 47.64 and 44.72 years old respectively, so there's little 101 difference between them. Among them, male workers aged 20-29 account for the lowest proportion (5.06%), female workers aged 40-49 account for the highest proportion (29.11%), and workers aged above 60 account for a quite high proportion (16.46%). The details are shown in Table 5-2. Table 5-2 Age Structure of Aged-care Service Workers with Different Genders Unit: % Age 60 years 20-29 30-39 40-49 50-59 old or years old years old years old years old above Male 5.06 3.80 12.66 3.80 10.13 Gender Female 8.86 7.59 29.11 12.66 6.33 Total 13.92 11.39 41.77 16.46 16.46 The survey also shows that workers in different types of aged-care service institutions have a great difference in age: the average age of workers in residential community-based and home-based aged-care service institutions is 38.7 years old, which is relatively low, and the average age of workers in urban and township reception type aged-care service institutions is 44.6 and 52.1 years old respectively. In residential community-based and home-based aged-care service institutions, non-nursing posts feature high proportion, relatively high income, relatively low work intensity, good working environment and conditions, so they can attract young workers, and the proportion of workers under 30 in this type of aged-care service institutions is quite high (37.5%). While the posts in township reception type aged-care service institutions are featured with low income, long working time, bad working environment and conditions and few development opportunities, it is difficult for them to attract young workers. In this type of aged-care service institutions, workers aged below 30 account for a very low proportion (6.3%) and they are engaged in non-nursing work, while workers aged above 50 account for over 50%. The details are shown in Table 5-3. 102 Table 5-3 Age Structure of Aged-care Service Workers in Different Types of Aged-care Service Institutions Unit: % Age 20-29 60 years 30-39 40-49 50-59 years old or years old years old years old old above Residential community-bas ed and home-based 11.39 2.53 8.86 6.33 1.27 aged-care service institutions Types of Urban aged-care reception type service aged-care 0.00 6.33 18.99 2.53 1.27 institutions service institutions Township reception type aged-care 2.53 2.53 13.92 7.59 13.92 service institutions Total 13.92 11.39 41.77 16.46 16.46 5.1.2 Educational level The survey shows that the average educational level of workers in the aged-care service institutions in the project area is relatively low, and that the proportion of workers with junior middle school education is the highest (30.4%), and the proportion of workers with bachelor degree or above accounts for only 5.1%. The educational level of workers in aged-care service institutions in the project area is negatively related to their ageâ‘ . This phenomenon has become a negative factor hindering the upgrading of the aged-care service. Person in charge of Aged-care Service Center of LashuYuan Community, Daguan District, Anqing City: We require the nursing staff to be under 50 years old, so that they can work for a â‘  Take the types of aged-care service institutions and gender as the control variables, and the partial correlation coefficient between the education level and the age of the workers in aged-care service institutions is -0.531 (the significance level of the double tailed test is 0.000) 103 longer time. The aged-care workers with more experience will be more popular. The workers over 50 years old may have poor physical condition, and they may become nursing objects in a few years. We mainly recruit workers from the surrounding rural areas, but the education level of them is not high, which is also a contradiction. People with a higher educational level can at least take on duty records and know the names of drugs for the elderly. The educational level of workers in different types of aged-care service institutions has a great difference: the average educational level of workers in urban residential community-based and home-based aged-care service institutions is the highest, and the proportion of workers with college degree or above accounts for 58.33% of total workers; the average educational level of workers in urban reception type aged-care service institutions is the second, and the proportion of workers with secondary school education accounts for 78.26%; the average educational level of workers in township reception type aged-care service institutions is the lowest, and the proportion of workers with middle or primary school education accounts for 71.88%. The details are shown in Table 5-4. Table 5-4 Structure of Educational Level of Aged-care Service Workers in Different Types of Aged-care Service Institutions Unit: % Educational level High Primary Junior school or Bachelor school middle technical College degree or and school secondary above below school Residential Types of community-based aged-care and home-based 8.33 16.67 16.67 45.83 12.50 service aged-care service institutions institutions Urban reception type aged-care 4.35 43.48 34.78 13.04 4.35 service institutions Township reception type 40.63 31.25 25.00 3.13 0.00 aged-care service institutions Total 20.25 30.38 25.32 18.99 5.06 104 5.1.3 Post, position and title 1) Post As most of the aged-care service institutions are small and lack of workers providing medical, health care, psychological counseling and other servicesâ‘ , the proportion of general nursing staff is the highest, and the proportion of administrative staff is high. The survey shows that the proportion of workers in nursing post (including general nursing and special nursing staff) in aged-care service institutions is about 43%, the proportion of workers in the administrative post and logistics post is 29% and 18% respectively, and the proportion of workers in medical, health care, security, accounting and other posts is quite low, with a total of 10.1%.The details are shown in Figure 5-1. 10.2 43 29.1 17.7 护ç?†äººå‘˜ å?Žå‹¤äººå‘˜ 行政管ç?†äººå‘˜ 其他人员 Figure 5-1 Post Distribution of Aged-care Service Institutions Unit: % 护ç?†äººå‘˜ Nursing staff å?Žå‹¤äººå‘˜ Logistics staff 行政管ç?†äººå‘˜ Administrative staff 其他人员 Other staff 2) Position The survey shows that the staff without position account for about 2/3 of workers in aged-care service institutions. About 1/3 staff have a post, including director, deputy â‘ Compared with the medical and health institutions, the income of medical and health care providers in aged-care service institutions is much lower; therefore, it's difficult for general aged-care service institutions to recruit these two types of workers. 105 director, finance supervisor (experience), director of the aged-care service center (station agent), security supervisor, logistics supervisor, etc.. 3) Title In the Chinese title assessment system, the medical, nursing, accounting and other staff of the aged-care service institutions can assess their titles, and many other staff do not have relevant title assessment. Since the nursing staff who account for the largest proportion in the project area are older and less educated, while logistics, security and other staff have no relevant title assessment, only 27.85% of staff in aged-care service institutions have junior and above titles. Among the staff with titles, the proportion of staff with junior title is 72.73%, and the proportion of staff with intermediate and senior titles is relatively low. The details are shown in Figure 5-2. 4.55 22.73 72.73 高级 中级 åˆ?级 Figure 5-2 Title Distribution of Aged-care Service Workers Unit: % 高级 Senior 中级 Intermediate åˆ?级 Junior 5.1.4 Working years and income 1) Working years Since the number of China's aged-care service institutions has increased substantially only in recent years, the majority of workers have worked in the aged-care service sector for a short period of time (less than 5 years).According to the survey, the longest working years of the respondents in aged-care service sector is 17 years, and 106 the shortest is 1 year, and the average working years is 5.2 years. Among them, the proportion of workers who have been employed for 1 year or less is the highest, 34.18%, and the proportion of workers who have been employed for 10 years or more is the lowest, 11.39%.The details are shown in Figure 5-3. 11.39 34.18 26.58 27.85 1å¹´å?Šä»¥ä¸‹ 2-5å¹´ 6-10å¹´ 10年以上 Figure 5-3 Structure of Working Years of Aged-care Service Workers Unit: % 1 å¹´å?Šä»¥ä¸‹ 1 year or less 2-5 å¹´ 2-5 years 6-10 å¹´ 6-10 years 10 年以上 More than 10 years 2) Income Because of the low requirements on technology, age and educational level, the income of the aged-care service workers in the project area is relatively low. The survey shows that the monthly income of aged-care service workers in the project area is no more than 6,000 Yuan, with an average monthly income of 2,316 Yuan. Among them, the proportion of workers with a monthly income of 2,000-4,000 Yuan is the highest (55.7%), and the proportion of workers with a monthly income of 4,000-6,000 Yuan is the lowest (1.3%). The details are shown in Figure 5-4. 107 1.3 6.3 36.7 55.7 1000元以下 1000-2000å…ƒ 2000-4000å…ƒ 4000å…ƒ-6000å…ƒ Figure 5-4 Monthly Income Distribution of Aged-care Service Workers Unit: % 1000 元以下 Below 1000 Yuan 1000-2000 å…ƒ 1000-2000 Yuan 2000-4000 å…ƒ 2000-4000 Yuan 4000-6000 å…ƒ 4000-6000 Yuan The partial correlation analysis shows that the income of workers in the aged-care service institutions is mainly related to the regional economic development level, post/position and gender, and there is no significant correlation between the income and age, working years and educational level. The income of workers in the aged-care service institutions is mainly positively related to the regional economic development level: The economic development level of Ningguo urban area is the highest, and the investigation sites are welfare homes in urban cities, therefore, the average income level of workers in the aged-care service institutions is the highest (2,864 Yuan/month), and more than 90% workers’ monthly income is 2,000-4,000 Yuan. The economic development level of Suzhou (township) is the lowest, and the investigation sites are rural nursing homes, therefore, the average income level of workers is the lowest (1,540 Yuan/month), and about 84% surveyed workers’ monthly income is below 2,000 Yuan. The economic development level of Wuhu and Xuancheng urban areas is relatively high, and the average income level of workers in the aged-care service institutions in these regions is relatively high (more than 2,500 Yuan/month). The monthly average income of workers in administrative posts is the highest, 2,826 Yuan, and about 82.6% of the administrative staff have monthly income of more than 2,000 Yuan. The monthly average income of workers in special nursing posts is the 108 second, 2,625 Yuan, and 75% workers in special nursing posts have monthly income of more than 2,000 Yuan. The monthly income of workers in logistics and general nursing posts is relatively low, with 71.43% and 57.69% workers earning less than 2,000 Yuan monthly (The details are shown in Table 5-5). In addition, the monthly average income (2,672 Yuan) of the workers with a position is significantly higher than that of the workers without a position (2,110 Yuan). Table 5-5 Income Structure of Aged-care Service Workers in Different Posts Unit: % Monthly income 1,000-2,000 2,000-4,000 4,000-6,000 Below 1,000 Yuan Post Yuan Yuan Yuan Special nursing 0 25 75 0 General nursing 11.54 46.15 42.31 0.00 Logistics 14.29 57.14 28.57 0.00 Administrative 0.00 17.39 78.26 4.35 management Others 0.00 37.50 62.50 0.00 There are gender differences in the income of aged-care service workers: The average monthly income of male and female workers is 2,607 Yuan and 2,157 Yuan respectively; 71.4% of male workers earn more than 2,000 Yuan a month, while only 49% of female workers earn more than 2,000 Yuan a month. The income differences between male and female workers are mainly due to gender differences in positions and posts: Nearly 50% of male workers have positions, while only 29.4% of female workers have positions; 62.75% of female workers engage in general nursing and logistics with lower income, while only 28.57% of male workers engage in general nursing and logistics. 5.1.5 Marital status At present, the aged-care service sector is unattractive for young job seekers, especially the adoptive aged-care service institutions, so the proportion of married workers in the aged-care service institutions in the project area is very high. The survey shows that 88.61% of the aged-care service workers are married, of which the number of workers who are married with spouse living is the largest, accounting for 84.81% of the total number of workers. The marital status is mainly related to age, 109 and most of the unmarried workers are no more than 26 years old. 5.2 The impact of the project on aged-care service workers The project may have a positive or negative impact on the employment, income, working environment and conditions, and promotion of the workers in aged-care service institutions involved in the construction of the project, since it involves the construction of building, living facilities, entertainment facilities, health care facilities and safety facilities, which will enhance the ability to provide aged-care service, and increase aged-care service recipients. The workers have a very clear understanding of it: The survey shows that 86.06% of the aged-care service workers believe that this project has a significant impact on them, and 65.82% of them think the project has a great or big impact on them, and only 3.8% of them say they are not aware of the impact of the project on themselves. Overall, the project objectives are consistent with the interest demands of aged-care service workers, so the final effect should be positive, which can also be verified by the self-assessment results of the workers in aged-care service institutions in the project area. The positive impact of this project on the aged-care service workers is significantly more than the negative impact. 5.2.1 Positive impact By improving the construction of hard environment like buildings, beds and facilities, and the construction of soft environment like information platform and staff training, this project can reduce the investment in relevant aged-care service institutions in the project area, improve their supply capacity and quality of aged-care service, and promote the demands of aged-care service. Thus it will have a positive impact on the aged-care service workers in three aspects: Firstly, it can increase employment opportunities for potential aged-care service workers, as well as chance of promotion for existing aged-care service workers. Secondly, it can improve the economic benefits of aged-care service institutions and increase the demand for aged-care service workers, and thus help improve the remuneration of workers. Thirdly, it is conducive to the physical and mental health of the elderly, and it can 110 improve the self-care ability of the elderly or reduce the workload of nursing staffâ‘ , thereby reducing the work intensity of nursing staff. Most aged-care service workers think that the project mainly has a positive impact on their working environment and conditions, income and so on. The survey shows that among aged-care service workers who think that the project has a significant impact on them, 61.67% and 41.67% respectively choose "working environment and conditions" and "income" in the question “What aspects does the project have a significant positive impact on you?â€?; and 8.33% and 6.67% choose "chance of promotion" and "work intensity". The details are shown in Figure 5-5. 3.336.67 8.33 6.67 41.67 61.67 收入 工作环境和æ?¡ä»¶ 工作强度 å?‡è¿?机会 其他 ä¸?知é?“ 收入 Income 工作环境和æ?¡ä»¶ Working environment and conditions 工作强度 Work intensity å?‡è¿?机会 Chance of promotion 其他 Others ä¸?知é?“ Unaware Notes: The data in the figure are the statistical results of answers of the aged-care service workers to the question “What aspects does the project have a significant positive impact on you?â€? (the proportions of the number of workers who choose “yesâ€? for each item in the number of workers who answer the question). Figure 5-5 Evaluation of the Project's Positive Social Impact by Aged-care Service Workers Unit: % â‘ For example, facilities such as intelligent beds, barrier-free facilities, and special toilets and bathrooms can improve the self-care ability of the half-disabled (demented) elderly or reduce the workload of the nursing staff. 111 5.2.2 Negative impact The implementation of the project may have a negative impact on the aged-care service workers in three aspects: Firstly, for aged-care service institutions involving the construction of housing, living and other facilities, the construction process may generate noise and dust pollution, and bring some security risks, which will have a negative impact on the working environment and conditions of workers in these institutions in the short term. In addition, a lot of old people need temporary transfer, which brings additional work to the staff, and increases the working time and work intensity of the staff in the short term. Secondly, after the completion of the project, and improvement of the capacity and quality of benefited aged-care service institutions, there may be a substantial increase in demand for aged-care service. In the case of the shortage of aged-care service workers, the working time and work intensity of many existing workers will rise. Thirdly, after the implementation of the project, part of the benefited aged-care service institutions may improve the requirements for aged-care service workers, or replace the existing nursing staff with low skills and educational level and older age with professional nursing staff with specialized education or training, which will have a negative impact on employment and income of part of the existing nursing staff. Overall, the aged-care service workers think that the project has neither much nor great negative impact on themselves. The survey shows that among aged-care service workers who think that the project has a significant impact on them, 23.73% and 20.34% respectively choose "work intensity" and "working time" in the question “What aspects does the project have a significant negative impact on you?â€?; and 8.47% and 6.78% choose "working environment and conditions" and "income". The details are shown in Figure 5-6. 6.67 6.78 8.47 27.12 23.73 1.69 3.39 20.34 收入 工作环境和æ?¡ä»¶ 工作强度 112 工作时间 å?‡è¿?机会 其他 ä¸?知é?“ æ— å½±å“? 收入 Income 工作环境和æ?¡ä»¶ Working environment and conditions 工作强度 Work intensity 工作时间 Working time å?‡è¿?机会 Chance of promotion 其他 Others ä¸?知é?“ Unaware æ— å½±å“? No impact Notes: The figure shows the statistical results of answers of the aged-care service workers to the question “What aspects does the project have a significant negative impact on you?â€? (the proportions of the number of workers who choose “yesâ€? for each item in the number of workers who answer the question). Figure 5-6 Evaluation of the Project's Negative Social Impact by Aged-care Service Workers Unit: % 5.2.3 The social impact that the aged-care service workers concern most Low income, poor working environment and conditions, and high work intensity are the common criticisms of the aged-care service workers in the project area. Therefore, the aged-care service workers in the project area are more concerned about the impact of the project on their working environment and conditions, income, and work intensity. The survey shows that 40.02%, 38.67%, and 16% of the workers choose "working environment and conditions", "income" and "work intensity", and no one chooses "working time" in the question “Among the above impacts, which impact do you concern most?â€? (The details are shown in Figure 5-7). 1.31 4.00 16.00 38.67 40.02 收入 工作环境和æ?¡ä»¶ 工作强度 è¿?å?‡æœºä¼š 其他 113 收入 Income 工作环境和æ?¡ä»¶ Working environment and conditions 工作强度 Work intensity è¿?å?‡æœºä¼š Chance of promotion 其他 Others Notes: The figure shows the statistical results of answers of the aged-care service workers to the question “Among the above impacts, which impact do you concern most?â€? (the proportions of the number of workers who choose “yesâ€? for each item in the number of workers who answer the question). Figure 5-7 The Social Impact That the Aged-care Service Workers Concern Most Unit: % The project impacts that the aged-care service workers in the project area concern about are mainly affected by two factors: One is the income of the aged-care service workers, and the other is the working environment and conditions of the aged-care service institutions. The aged-care service workers with lowest income are often of high age and relatively low economic pressure, so they are not so concerned about the income, and they concern most about the working environment and conditions. Most of the workers with low income (1,000-2,000 Yuan/month) are at the age of 30-50; they are young and strong and their family economic pressure is relatively large, so they concern most about income, and concern less about the work intensity, working environment and conditions, etc.. Among the aged-care service workers with high income (2,000-4,000 Yuan/month), people no more than 45 years old account for 55.81%, and people no more than 35 years old account for 37.2%; they are most concerned about the impact of the project on the working environment and conditions, but also concerned about the impact of the project on income, work intensity, chance of promotion, etc.. The details are shown in Table 5-6. The working environment and conditions of most of the aged-care service institutions in the project area are relatively poor, especially the houses and buildings and living infrastructure of many rural reception type aged-care service institutions are very old and crude. Therefore, the workers of these aged-care service institutions are most concerned about the impact of the project on the working environment and conditions, 114 and have great expectations for improving their working environment and conditions. Table 5-6 The Project Impact that the Aged-care Service Workers with Different Income Concern Most Unit: % The most concerned project impact Working Total Income environment Work Chance of Others and intensity promotion conditions Below 1000 19.56 59.87 20.57 0.00 0.00 100.00 Yuan 1000-2000 65.38 19.23 11.54 0.00 3.85 100.00 Income Yuan 2000-4000 25.58 48.84 18.60 2.33 4.65 100.00 Yuan 4000-6000 0.00 100.00 0.00 0.00 0.00 100.00 Yuan 5.2.4 The impact difference of sub-projects on aged-care workers in different cities Seen from the sub-projects of different cities, due to the difference in nature and type of the project, there are differences in the impact on the aged-care workers. The World Bank project plans to set up care and rehabilitation center for the elderly people in the newly built multi-functional medical building of Traditional Chinese Hospital of Lu An, build a nursing home for the elderly people in First People’s Hospital of Anqing, and build a health and aged-care center building in Wuhu Sixth People's Hospital. The construction of these integrated medical and aged-care institutions has almost no influence on the existing caregivers and professional management staff in hospitals. It’s because these regular hospitals' recruitment, benefits and doctor-nurse ratio are very standardized. The construction of new integrated medical and aged-care institutions will not change the established rules and regulations and personal benefits. Traditional Chinese Hospital of Lu An's management staff 1: After the completion of the care and rehabilitation center for the elderly people, the hospital will keep contact with it. For example, the recruitment and training of new staff need the support of the hospital, and the hospital will adopt the principle of "promoting the new staff with the old staff". In addition, the hospital is the main unit of construction, and the aged-care center is an affiliated institution of the hospital, which should be managed by the hospital. 115 Traditional Chinese Hospital of Lu An's nursing staff 2: The completion of the center is definitely a great thing. Such a medical and aged-care institution can reduce the burden on the family. The children also need such a secure place to put the family members in. It feels good to work here. We are all nursing majors, graduating from nationally recognized universities. Our wages are paid in accordance with state regulations, but we enjoy the wage performance of public institution, and the performance varies from department to department. In general, hospital's performance wage is good. Of course, I'd like to be further improved in terms of title. Now, in clinical rehabilitation, it's all right to add one or two employees for rehabilitation nursing. The World Bank project plans to carry out relocation and reconstruction of Xuancheng Municipal Social Welfare Home, and carry out transformation of Ningguo Municipal Social Welfare Home. These works will have a great impact on caregivers. The Xuancheng Municipal Social Welfare Home was established in June 1983, with a land area of 18 mu, a total construction area of about 6,000 square meters, a total of 280 beds, and 43 employees. It's situated beside Shuiyangjiang River at the southern foot of "Jingtingshan Mountain", which is a famous scenic spot of Xuancheng. It's situated beside a river at the foot of a mountain, and the traffic is very convenient. As a result of municipal road construction, the Xuancheng Municipal Social Welfare Home needs to be relocated. The new site is finally selected to be the southwest of Xiadu Xincheng Community of Xuanzhou District after many setbacks. The new social welfare home covers an area of 61.35 mu. It will be greatly improved in light of the working environment and hardware facilities, and the surrounding environment is good. This will improve the satisfaction of the caregivers. In addition, adding beds can also increase the number of elderly not enjoying the five guarantees who accept self-supporting, which will improve the benefits of caregivers. But because the new site is located in the urban fringe, the negative impact of the change of address on the caregivers is firstly the extension of commuting time. The second impact is that the beds are increased from 280 original beds (including 16 beds for children) to 400 beds, which will increase the work intensity of existing caregivers. Even if more workers are employed, they need a transition period for training. Our survey shows that 100% of nursing staff support the World Bank project. Of which, the nursing staffs who think that the World Bank project should improve the 116 welfare home's environment account for 42.9%, and those who support effective training of service personnel and purchase of various facilities account for 28.6%. According to the satisfaction survey of the current situation, few nursing staff are satisfied with the current benefits (those who select "ordinary" account for 71.4%, and those who select "poor" account for 28.6%); 57.1% of nursing staff think the current working time is too long; and 71.5% of nursing staff think the present work intensity is large. During the survey, we have repeatedly asked the staff, which one you choose: recruiting more caregivers in the new welfare home and maintaining the current work intensity, or raising wage without recruitment of new caregivers. Most of the staff have chosen to raise wages, which shows that bed adding in the new welfare home will expand the scale of the elderly not enjoying the five guarantees, thus increasing the staff's wages. It can make up for the impact of increase in work intensity to a certain extent. Director: 20 employees among 33 employees are paid with basic salary of 1,450 Yuan by finance, and the remaining 13 employees are paid by the funds of self-supporting elderly not enjoying the five guarantees, with an average income of about 2,300-2,500 Yuan, which is relatively low in the city. City people are reluctant to do this, even including laid-off workers. A lot of nursing workers are recruited from the rural areas of surrounding suburbs; they are a little bit old, but are tough. Rural nursing homes serve the people enjoying five guarantees in rural areas. In order to ensure the normal operation of the nursing home, the support funds, staff's wages (charge for procurement of aged-care services) and management funds of nursing home are incorporated into the county budget. The wages of employed personnel are not less than the local minimum wage, which is 1,300 Yuan/month in Suzhou. The staff in the nursing home have a very low wage, who are basically 40 years old to 50 years old, with low educational level. In addition, the equipment in nursing home is old, and the general vacancy rate is 50%. In view of this, Auhui Province promotes the transformation and upgrading of nursing homes. Nursing homes can use their existing vacant beds to accommodate the elderly not enjoying the five guarantees, and then use the money earned to support the operation of the nursing homes and help 117 increase the income of staff. This project will upgrade and transform 35 rural nursing homes in Suzhou, upgrade the hardware and software of the nursing homes, reduce the vacancy rate, expand the centralized support scale of the elderly enjoying five guarantees and the elderly not enjoying the five guarantees, and increase new staff recruitment. Unemployment, job transfer and other issues will not occur in the existing caregivers and professional management staff, instead, the project will beautify their working environment and improve their income level. Therefore, they are very supportive of the project. But the upgrade involves not just hardware improvements, and guaranteeing elderly enjoying five guarantees and San Wu elderly, but also involves the service upgrade, radiating the service to the surrounding, and providing home-based care services, for example, providing visiting service to the decentralized rural elderly. This service upgrade will result in higher requirements for employees, which seems to have not been considered by the nursing homes at present. According to the project proposal and feasibility study report of various regions, the World Bank project will build 34 home-based aged-care service stations in Lu An, build 127 home-based aged-care service stations in Anqing, build 8 chain community and home-based health and aged-care service centers in Wuhu, and implement the purchase of home-based aged-care service by government in Lu An and Anqing. The common ground of the three cities is that they will adopt the mode of public construction and private operation, and introduce social forces into operation. The institutional change may have a certain impact on full-time elderly assistant and full-time staff in charge of aging work in the community equipped for the former sub-district, as well as newly employed caregivers and professional management staff in aged-care service institutions. It should be said that Anhui Province has paid much attention to aged-care in urban community for the past few years. It has been strengthening the construction of three-level management network, in order to establish a three-level network system of community and home-based aged-care service guidance center at county (city, district) level, community and home-based aged-care service management center at township 118 (street) level and home-based aged-care service center at community level, but the actual effect is not very ideal. Anqing Bureau of Civil Affairs: Previously, almost 175 communities have home-based aged-care service stations, most of which are left unused, and few or even none of them are providing services. Lu An Bureau of Civil Affairs: The former home-based care stations are arranged at each community, but the stations' utility is not good enough; they have low utilization rate, and have not attracted enough people. Wuhu Bureau of Civil Affairs: 79 day care centers built according to the standards of the Ministry of Civil Affairs do not play a role, and the services provided to the community elderly cannot meet the demand. So many centers have been built, and it's a waste of resources to abandon them. One of the reasons for this situation is the excessive delegation of tasks to the residential community (a grass-roots autonomous organization) in providing services. The community staff are not full-time staff for aged-care, and it is difficult for them to adapt to various demands on aged-care service of the aged, a special group. Grass-roots community organizations are already short of funds and staff, so they are unable to cover more aged people in need. The community neighborhood committee's responsibility for aged-care service is over expanded, so it's doing something that it can't do well or is unable to do. In view of the poor effect of the government arranged community-based aged-care service model, the government has begun to introduce social forces, and gradually separate some aged-care service stations from residential communities to operate separately. According to our survey, the socialized management of community aged-care station has freed the community sub-district workers from the burdensome aged-care service, to focus on other social services they previously concerned. Or their focus will be shifted to supervision and evaluation of the quality of institutional care service for the aged (third party supervision) and research of supply and demand situation of aged-care service market, etc.. Therefore, the implementation of the project will not result in unemployment, job transfer, or distribution of them. 119 Person in charge of Aged-care Service Center of Lu An City: Aged-care is the task of the residential community, but the community's task is too large. Every community has aged-care receivers, but the community staff have no energy for too many things. We are assistants of community staff, and we accept supervision as supervision is very good. The second cause of this situation is that the government has not planned well on funds, sites, support policy and implementation plan. One house is used for multiple purposes in some residential communities. If these "vacant" houses are not used as aged-care centers for institutions, the community sub-districts can rent them out, and charge some rent every year. So some staff of sub-district communities are reluctant to use these "vacant" houses as aged-care centers for institutions, as their workloads will not be reduced, and their income will not increase. The implementation of the World Bank project may exert the following impact on caregivers and professional management staff of aged-care service institutions providing socialized services: It may increase their work intensity (especially at the beginning), but can also provide high level of training and promotion opportunities, increase subsidies (transportation costs or maintenance costs of transport, communication costs, catering allowance, etc.), equip with new means of transportation and intelligent equipment, and even raise wages, so as to minimize or offset the increase in work intensity. 6. Influence of the Project on the Aged and Their Family Members The aged-care cause relates not only to the vital interests of the aged but also that of their family members. The aged and their family members are the buyer, consumer and final beneficiary of institutional care, community-based aged-care, home-based aged-care and integrated medical and aged-care service. The World Bank-financed Anhui Aged-care System Project will exert direct or potential influence on the aged and their family members: direct influence on the aged who are receiving the aged-care service incorporated in the World Bank-financed Project and their family members, and potential influence on the aged not receiving aged-care service and 120 their family members in the project areaâ‘ . Due to the lack of statistic data, it is difficult for us to understand the overall situation of the aged who receive or not receive aged-care in the project area. The data of this part are deprived from two investigations make by our social evaluation team: (1) From March 1, 2017 to March 17, 2017, total 162 elderly people receiving care and their family members in 24 aged-care institutions in the project area (5 cities) were subject to questionnaire, including 54 elderly people in the urban community and home-based aged-care institutions, 58 in the urban reception type aged-care institutions, 50 in the township reception type aged-care institutions and 10 family members. The evaluation of the family members on the influence of service and items of the aged-care institutions is fairly consistent with the evaluation of the aged receiving care, thus the evaluations are integrated for analysis. (2) During June 28 to July 3, 2017, the aged not receiving relevant aged-care service and their family members in one hospital (Traditional Chinese Hospital of Lu An, total 128 elderly people and family members were visited and 118 effective questionnaires were returned), two communities (Renmin Xincun Community in Zhongshi Street, Jin’an District and Qing’an Community in Gulou Street, Yu’an District, Lu An City, total 42 elderly people and family members were visited and 42 effective questionnaires were returned), three villages & towns (Zhenbei Village, Beiyangzhai Town, Yongqiao District, Suzhou City, Gaozhai and Houzhu villages, Fengmiao Town, Lingbi County, Suzhou City and Qiumiao and Hongguang villages, Yangtuan Town, Lingbi County, Suzhou City, total 54 elderly people were visited and 54 effective questionnaires were returned) in the project area (Lu An and Suzhou cities) were subject to questionnaire. 6.1 Influence of the project on the aged who have received the aged-care service and their family members 6.1.1 Basic information of the aged who have received the aged-care service 1) Gender and age Gender. In the aged who have received the aged-care service, 62.96% are female, â‘  The death of individual elderly people during the project will not be considered in the analysis. 121 obviously more than male. Where the female elderly people receiving care are more than male in the township reception type aged-care institutions and urban community-based and home-based aged-care institutions, while less than male in the urban reception type aged-care institutions. Age. The aged are aged from 49 to 96, with average age of 76.48, the mode age is 73 (16 elderly people). Where, the aged 70-79 takes the highest proportion (54.32%); and the aged under 60 years old and above 90 years old take low proportion, total 8.64%. See Figure 6-1 for details. The aged receiving care who is below 60 years old are disabled elderly people/elderly people with dementia with financial difficulty, living in government-sponsored nursing homes or welfare homes. 54.32 60.00 50.00 40.00 25.93 百分比（%） 30.00 20.00 11.11 6.17 10.00 2.47 0.00 60周å²?以下 60-69周å²? 70-79周å²? 80-89周å²? 90周å²?å?Šä»¥ä¸Š 年龄 百分比（%） Percentage (%) 60周å²?以下 <60 yrs 60-69周å²? 60-69 yrs 70-79周å²? 70-79 yrs 80-89周å²? 80-89 yrs 90周å²?å?Šä»¥ä¸Š ≥90 yrs 年龄 Age Figure 6-1 Age Structure of the Aged Receiving Care 2) Educational level and income Educational level. The aged receiving care generally have low educational level: 78.48% are primary school or junior high school graduates, where nearly 70% are primary school graduates or below, and the junior college graduates take only 5.06%. See Figure 6-2 for details. 122 5.06 大专 16.46 高中或中专 文化程度 8.86 åˆ?中 69.62 å°?å­¦å?Šä»¥ä¸‹ 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 百分比（%） 文化程度 Educational level 大专 Junior college 高中或中专 High school or technical secondary school åˆ?中 Junior middle school å°?å­¦å?Šä»¥ä¸‹ Primary school and below 百分比（%） Percentage (%) Figure 6-2 Educational Level Structure of the aged Receiving Care There is significant educational level difference between the urban and rural elderly people receiving aged-care service. The township reception type aged-care institutions receive poor rural elderly peopleâ‘ , therefore, the aged in these institutions are much lower in educational level than the other two types of institutions, where 92% are primary school graduates or below. The urban community-based and home-based aged-care institutions provide aged-care service to the retired elderly people with higher consumption power; therefore, the elderly people receiving care in such institutions are higher in light of educational level, 36% are senior high school graduates or above. See Figure 6-3 for details. â‘ Include the “San Wu Peopleâ€? (the aged who are not able to work, have no source of living and have no one to support them), disabled elderly people/elderly people with dementia with financial difficulty, and elderly people with low income. 123 0.00 大专 6.90 8.00 4.00 高中或中专 17.24 文化程度 28.00 4.00 åˆ?中 10.34 12.00 92.00 å°?å­¦å?Šä»¥ä¸‹ 65.52 52.00 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 100.00 百分比（%） 城市社区和居家养è€?æœ?务机构 城区收养性养è€?æœ?务机构 乡镇收养性养è€?æœ?务机构 文化程度 Educational level 大专 Junior college 高中或中专 High school or technical secondary school åˆ?中 Junior middle school å°?å­¦å?Šä»¥ä¸‹ Primary school and below 百分比（%） Percentage (%) 城市社区和居家养è€?æœ?务机构 Urban community-based and home-based aged-care institutions 城区收养性养è€?æœ?务机构 Urban reception type aged-care institutions 乡镇收养性养è€?æœ?务机构 Township reception type aged-care institutions Figure 6-3 Educational Level Structure of the Elderly Receiving Care in Different Aged-care Institutions Income. The aged receiving care have an average income of 1,221 Yuan/month, where 23.38% have no income, 36.36% have less than 1,000 Yuan/month and only 1.3% have more than 4,000 Yuan/month. There is a significant income difference among the aged receiving care in different aged-care institutions: the aged in urban community-based and home-based aged-care institutions have an average monthly income of 1,688 Yuan, where 41.67% have more than 2,000 Yuan/month and only 4.17% have no income; the elderly people in urban reception type aged-care institutions have an average monthly income of 1,414 Yuan, where 34.48% have more than 2,000 Yuan/month, 31.03% have no income; the aged in township reception type institutions have an average monthly income of 521 Yuan, where only 4.17% have more than 2,000 Yuan/month and 87.5% have less than 1,000 Yuan/month. See Figure 6-4 for details. 124 0.00 4000-6000å…ƒ 3.45 0.00 4.17 2000-4000å…ƒ 31.03 41.67 月收入 8.33 1000-2000å…ƒ 13.79 16.67 54.17 1000元以下 20.69 37.50 33.33 无收入 31.03 4.17 0.00 10.00 20.00 30.00 40.00 50.00 60.00 百分比（%） 城市社区和居家养è€?æœ?务机构 城区收养性养è€?æœ?务机构 乡镇收养性养è€?æœ?务机构 月收入 Monthly income 4000-6000å…ƒ 4,000~6,000 Yuan 2000-4000å…ƒ 2,000~4,000 Yuan 1000-2000å…ƒ 1,000~2,000 Yuan 1000元以下 Less than 1,000 Yuan 无收入 No income 百分比（%） Percentage (%) 城市社区和居家养è€?æœ?务机构 Urban community-based and home-based aged-care institutions 城区收养性养è€?æœ?务机构 Urban reception type aged-care institutions 乡镇收养性养è€?æœ?务机构 Township reception type aged-care institutions Figure 6-4 Income Structure of the Aged Receiving Care in Different Aged-care Institutions There is a positive correlation between the income of the aged receiving care and their educational level (correlation coefficient 0.504, significance level 0.000). The elderly people with primary school degree and below have an average monthly income of 796 Yuan, while the elderly people with junior college degree have an average monthly income of 3,500 Yuan, 4.4 times the former. 3) Reception or care of the aged care objects guaranteed by the government The objects of aged-care service guaranteed or wholly supported by the government include the “San Wu peopleâ€?, the disabled elderly people/elderly people with dementia with financial difficulty and the low-income elderly people, mainly received by the urban and rural government-sponsored and social capital invested reception type aged-care institutions (welfare home, nursing home). According to investigation, the township reception type aged-care institutions in the project area hardly ever receive or nurse the elderly not enjoying the five guarantees, 87.5% of the elderly people receiving care in such institutions are the objects of the 125 above three kinds guaranteed by the government (79.17% are the “San Wu peopleâ€?). The urban reception type aged-care institutions in the project area have widened the reception objects through government-sponsored and private-operated, private-sponsored and private-operated, government-sponsored and government-operated socialization and other modes, they will not be limited to receive or nurse the government guaranteed objects; therefore, only 32.14% of the aged receiving care in such institutions are the objects of the above three kinds guaranteed by the government (14.29% are the “San Wu peopleâ€?). Urban community-based and home-based aged-care institutions also receive or nurse the disabled elderly people/elderly people with dementia with financial difficulty and the low-income elderly, but it just takes a low proportion (less than 1/4). Table 6-1 Proportion of the Received or Cared Elderly People Guaranteed by the Government in Different Aged-care Institutions Unit: % Type of the aged Disabled elderly people/elderly The “San Wu people with low-incom Others peopleâ€? dementia with e elderly financial difficulty Urban community-base d and 0 4.17 20.83 75.00 home-based Type of aged-care the institutions aged-care Urban reception institution type aged-care 14.29 3.57 14.29 79.17 s institutions Township reception type 79.17 8.33 0.00 12.50 aged-care institutions 4) Self-care ability and the distance from home address Self-care ability. According to investigation, 55.56% of the elderly people in the aged-care institutions in the project area are completely self-reliant, 24.69% are generally self-reliant, only 4.94% are non-self-reliant. See Figure 6-5 for details. 126 However, according to communication and observation, the proportion of the disabled elderly people/elderly people with dementia is not that low. There are mainly two reasons for such situation: the first is the limitation of the nursing capability of many aged-care institutions in the project area, they are poor in providing treatment, physiotherapy and health care and they are unwilling or unable to receive the (partially) disabled elderly people/elderly people with dementia who need the care most. The second is the communication difficulty of the disabled elderly people/elderly people with dementia, which hinders the investigation, resulting in error in selection of respondents, underestimating the proportion of the (partially) disabled elderly people/elderly people with dementia. 4.94 14.81 55.56 24.69 能完全自ç?† 能基本自ç?† 能部分自ç?† ä¸?能自ç?† 能完全自ç?† Completely self-reliant 能基本自ç?† Generally self-reliant 能部分自ç?† Partially self-reliant ä¸?能自ç?† Non-self-reliant Figure 6-5 Proportion of the aged Receiving Care with Different Self-care Abilities unit: % The distance from home address. The homes of 82.28% of the elderly people receiving care are close to the aged-care institution, and about 10% of the elderly people’ homes are relatively far or very far away from the institution. Limited by the region of pension subsidy and being strongly self-reliant, most of the aged received or nursed in the township reception type aged-care institutions choose to receive care in the township institutions near their homes so that they can go home frequently. The aged whose homes are far away from the institutions are generally receiving care in the urban reception type aged-care institutions. 5) Marital status 127 Out of the aged receiving care, 50.65% are widowed, and 15.58% are unmarried (see Figure 6-6). The unmarried elderly people are generally from rural areas, receiving care in the urban reception type aged-care institutions and township reception type aged-care institutions. 15.58 33.77 50.65 é…?å?¶å?¥åœ¨ 丧å?¶ 未婚 é…?å?¶å?¥åœ¨ Spouse alive 丧å?¶ Widowed 未婚 Unmarried Figure 6-6 Marital Status of the Aged Receiving Care unit: % 6) Children The aged receiving care have 0~6 children, and 1.94 (1 son and 0.94 daughter) in average. Over 1/3 of the aged receiving care have no child, far above the China’s average level, and among the aged with no child, 88.46% are “San Wu peopleâ€?. See Figure 6-7 for details. 2.60 7.79 6.49 33.77 24.68 10.39 14.29 0个 1个 2个 3个 4个 5个 6个 0个 0 1个 1 2个 2 3个 3 128 4个 4 5个 5 6个 6 Figure 6-7 Number of Children of the aged Receiving Care unit: % 7) The existing and expected aged-care modes The existing aged-care mode. 76.54% of the aged receiving care live in aged-care institutions, thus we conducted the survey mainly in aged-care institutions. 12.35% of the aged who receives care live alone but children or volunteers visit from time to time, 9.88% of the aged live with their children. 1.23 其他 3.70 12.35 独居但有人探视 14.81 76.54 ä½?å…»è€?机构 58.02 9.88 与å­?女å?Œä½? 23.46 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 期望的养è€?æ–¹å¼? 当å‰?çš„å…»è€?æ–¹å¼? 其他 Others 独居但有人探视 Live alone but being visited from time to time ä½?å…»è€?机构 Live in the aged-care institution 与å­?女å?Œä½? Live with children 期望的养è€?æ–¹å¼? The expected aged-care mode 当å‰?çš„å…»è€?æ–¹å¼? The existing aged-care mode Figure 6-8 The Existing and Expected Aged-care Modes for the Aged Receiving Care unit: % The expected aged-care mode. The expected aged-care mode is closely related to the existing aged-care mode of the aged, about 79% of the elderly people expect the same mode as the existing mode. According to Figure 6-8, only the institutional care service for the aged shares a decreased ratio in the expected aged-care modes, while other modes share increased ratio. Over 1/4 of the elderly people who are receiving institutional care service for the aged don’t want to live in the aged-care institution anymore and most of them want to live with their children. It is possibly related to the traditional idea of aged-care and the dissatisfaction to the service of the aged-care institution. 129 6.1.2 Influence of the project on the aged who have received the aged-care service and their family members 1) The awareness of the aged receiving care to the influence of the project 92.41% of the aged receiving care believes that the project will exert influence on them, where total 73.42% thinks it is significant and great influence (see Figure 6-9). There is awareness difference on the influence of the project among the aged receiving care in different types of aged-care institutions: 87.5% of the aged receiving care in the township reception type aged-care institutions thinks that the project will exert significant and great influence on them, much higher than 70.37% in the urban community-based and home-based aged-care institutions and 64.28% in urban reception type aged-care institutions (see Figure 6-10). As a result, the aged in township reception type aged-care institutions expect more to the project. 7.59 10.13 31.65 8.86 41.77 å½±å“?很大 å½±å“?较大 å½±å“?一般 å½±å“?较å°? æ— å½±å“? å½±å“?很大 Significant influence å½±å“?较大 Great influence å½±å“?一般 General influence å½±å“?较å°? Little influence æ— å½±å“? No influence Figure 6-9 The Evaluation of the Aged Receiving Care to the Influence of the Project unit: % 130 60.00 50.00 40.00 30.00 20.00 10.00 0.00 城市社区和居家 城区收养性养è€? 乡镇收养性养è€? å…»è€?æœ?务机构 æœ?务机构 æœ?务机构 å½±å“?很大 33.33 10.71 54.17 å½±å“?较大 37.04 53.57 33.33 å½±å“?一般 3.70 14.29 8.33 å½±å“?较å°? 18.52 10.71 0.00 æ— å½±å“? 7.41 10.71 4.17 城市社区和居家养è€?æœ?务机构 Urban community-based and home-based aged-care institutions 城区收养性养è€?æœ?务机构 Urban reception type aged-care institutions 乡镇收养性养è€?æœ?务机构 Township reception type aged-care institutions å½±å“?很大 Significant influence å½±å“?较大 Great influence å½±å“?一般 General influence å½±å“?较å°? Little influence æ— å½±å“? No influence Figure 6-10 The Evaluation of the aged Receiving Care in Different Types of Aged-care institution to the Influence of the Project unit: % 2) Positive influence of the project The project will establish new concentrated residence-based care services, construct, reconstruct & extend standard community aged-care service networks, upgrade and rebuild the rural nursing home, develop government-financed services and reconstruct the community embedded nursing centers for the disabled and semi-disabled elderly people to improve the aged-care service quality, improve living environment, meet the aged-care service needs of the aged in different levels and benefit the family members of the aged. Therefore, the aged receiving care and their family members in the project area support the project construction. According to the investigation, the aged who receive care generally express a high degree of support to the project: 74.07% are “strongly supportive of" the project and 19.75% are “comparatively supportive ofâ€? it, reaching up to 93.83% in total. 3) Negative influence of the project The project may exert negative influence on the aged receiving care and their family 131 members in two aspects: The first is that the aged-care service price may rise. The improvement of quality indicates a possible increase of price. The aged and their family members are sensitive to the price change before and after the project. For example, Ningguo Social (Children) Welfare Home will take the opportunities brought by the World Bank-financed project to demolish the old building named “Paradise of Luckâ€? and build a comprehensive building-Service Center for the aged instead for nursing the aged (receive self-paying elderly not enjoying the five guarantees). The new center will charge 1,320 Yuan/month, 330 Yuan higher than the previous level (990 Yuan/month), which causes complaints from some elderly people. Thus, the welfare home’s head said they will further publicize and explain the accommodation and cost of the new building and come up with solution: if the aged want to keep the original cost, they will be distributed to other similar apartments after demolition of the old building, if they want to live in the new building without additional payment, the current one-man room may be changed to two-men room to reduce the cost. If the aged enjoy a rapid increase of income (pension, annuity), to a large extent, it can offset the negative influence of the increase of aged-care price in several years. During the survey in some activity centers for the aged, we heard from some elderly people many times that if the free services and facilities (chess and cards room, activity center for the aged) will be charged in the future, they will not come here anymore. Therefore, the negative influence of charging and price change should be taken into consideration for the design and implementation of the project. The second is that the construction may cause noise, dust pollution and bring certain potential safety hazard, so as to influence the living environment of the aged negatively in a short period. Moreover, many elderly people need to be relocated temporarily, which may lead to life inconvenience and the aged may experience an adaptive process to the new environment. Nurse in Ningguo Social Welfare Home: I have been working here for 14 years on the preparation of the welfare home standardization. The aged will experience an adaptive process in the beginning, they are particularly sensitive to eating, sleeping, emotion, communication and environment adaption, we will pay special attention to their condition. 132 6.2 Potential influence of the project on the aged not receiving the aged-care service and their family members The aged not receiving aged-care and their family members in the branch project places of the project area are the main potential beneficiaries (possible beneficiaries), and the project exerts potential positive influence on them. The project focuses on the diverse demand of the aged, thus we investigate the potential beneficiaries of two subprojects - integrated medical and aged-care service project and rural nursing home upgrading project, because there is significant difference between the two projects on service contents, objects and regions. See the separate analysis below. 6.2.1 Potential influence of the integrated medical and aged-care service project on the aged not receiving the aged-care service 1) Basic information of the aged (a) Gender and age Gender. Of those elderly interviewed, the male and the female account for 61% and 39% respectively, which shows a significant higher proportion of the male than the female. Age. The aged interviewed age from 50 to 92, with average age of 70. Over 3/4 of the aged age 60-79, and the aged of above 90 years old take a very low proportion (1.69%). While the aged of 70 to 79 years old and 60 to 69 years old accounts for 38.98% and 37.29% respectively. See Figure 6-11 for details. 37.29 38.98 40.00 35.00 30.00 25.00 百分比% 20.00 11.86 15.00 10.17 10.00 5.00 1.69 0.00 50-59 60-69 70-79 80-89 90å?Šä»¥ä¸Š 年龄 百分比% Percentage (%) 133 90å?Šä»¥ä¸Š ≥90 yrs 年龄 Age Figure 6-11 Age Structure of the aged unit: % (b) Marital status Of those who have spouse alive account a high proportion of 69.49%, followed by the widowed elderly people of 22.03%. The divorced and single elderly people account for a quite low proportion. See Figure 6-12 for details. 5.08 3.39 22.03 69.49 é…?å?¶å?¥åœ¨ 丧å?¶ 离异 å?•èº« é…?å?¶å?¥åœ¨ Spouse alive 丧å?¶ Widowed 离异 Divorced å?•èº« Single Figure 6-12 Marital Status of the aged unit: % (c) Educational level The aged with primary school degree and below account for the highest proportion (45.8%) in the aged interviewed, including many illiterates; followed by the aged with middle school degree (44.1%); and the aged with junior college degree and above account for 10.2%, much higher than the average level of towns in China. See Figure 6-13 for details. 134 5.1 5.1 11.9 45.8 32.2 å°?å­¦å?Šä»¥ä¸‹ åˆ?中 高中或中专 大专 本科å?Šä»¥ä¸Š å°?å­¦å?Šä»¥ä¸‹ Primary school and below åˆ?中 Junior middle school 高中或中专 High school or technical secondary school 大专 Junior college 本科å?Šä»¥ä¸Š Bachelor and above Figure 6-13 Educational Level of the aged unit: % (d) Income and source The aged interviewed have a monthly income of 300~5,000 Yuan, with average of 2,072 Yuan. While the aged with average monthly income of 2,000-4,000 Yuan account for the highest proportion (45.45%) and the aged with average of more than 4,000 Yuan account for the lowest (10.91%). 10.91 4000-6000 月å?‡æ”¶å…¥ï¼ˆå…ƒï¼‰ 45.45 2000-4000 27.27 1000-2000 1000以下 16.36 0.00 10.00 20.00 30.00 40.00 50.00 百分比% 月å?‡æ”¶å…¥ï¼ˆå…ƒï¼‰ Average monthly income (Yuan) 1000以下 Less than 1,000 百分比% Percentage (%) Figure 6-14 Income of the aged There is a significant positive correlation between the income and educational level of 135 the aged. The average monthly income of the aged with primary school degree and below, junior high school, senior high school or technical secondary school, junior college degree, bachelor and above are 1,723, 2,095, 2,383, 2,767 and 3,400 Yuan respectively. Table 6-2 Cross Table of the Income and Educational Level of the aged unit: person Educational level High Primary school Junior Bachelor school or Junior Total middle and and technical college school above below secondary school Less than 14 4 0 0 0 18 1,000 Yuan 1,000~2,000 14 12 4 0 0 30 Yuan 2,000-3,000 14 12 4 4 0 34 Monthly Yuan income 3,000~4,000 2 8 2 0 4 16 Yuan 4,000~5,000 0 2 2 2 2 8 Yuan More than 4 0 0 0 0 4 5,000 Yuan Total 48 38 12 6 6 110 Note: there are 8 default values for the income. The income sources of the aged include pension, children support, labor, spouse support, annuity. Among which, half of the aged get their income from pension, 22.22% from children support, and many from farming and part-time jobs. The aged who have pension have the highest average monthly income of 2,511 Yuan. (e) Proportion of the aged-care objects guaranteed by the government Among the aged interviewed, the “San Wu peopleâ€?, disabled elderly people/elderly people with dementia with financial difficulty guaranteed or wholly supported by the government account for 5.1% in total. (f) Self-care ability The aged interviewed are highly self-reliant, 86.4% are completely and generally self-reliant, and 5.1% are non-self-reliant. 136 5.1 8.5 50.8 35.6 能完全自ç?† 能基本自ç?† 能部分自ç?† ä¸?能自ç?† 能完全自ç?† Completely self-reliant 能基本自ç?† Generally self-reliant 能部分自ç?† Partially self-reliant ä¸?能自ç?† Non-self-reliant Figure 6-15 Self-care Ability of the aged unit: % (g) Health care expenditure The health care expense of the aged interviewed account for a higher proportion in all consumption expenditures: average monthly expense of 548 Yuan, or 36.24% of the average monthly consumption expenditure. (h) The existing and expected aged-care modes The existing aged-care mode. Most of the aged interviewed are receiving home-based aged-care. Among which, 45.76% of the aged live with their children; 37.28% live with their spouse with frequent/ occasional visitors; 10.17% live alone (widowed, divorced, single) with visitors. 3.39% live in reception type aged-care institution for aged-care. Most of the young in Lu An city go out to work for a living, thus the aged who are not living with their children are empty-nest elderly people, when they experience a significantly decreased self-care ability in the future, some must rely on the institutional aged-care, and some elderly people and their family members expressed such intention during interview, which was reflected by the expected aged-care mode of the aged. 137 6.78 10.17 与å­?女å?Œä½? 与è€?伴一起生活，å­?女ç»?常 探视 45.76 15.25 与è€?伴一起生活，很少有人 探视 一个人独居，å­?女或亲å?‹ç»? 常探视 其他 22.03 与å­?女å?Œä½? Live with children 与è€?伴一起生活，å­?女ç»?常探视 Live with spouse, with regular children visits 与è€?伴一起生活，很少有人探视 Live with spouse, with seldom visits 一个人独居，å­?女或亲å?‹ç»?常探视 Live alone, with frequent children or relatives and friends visits 其他 Others Figure 6-16 The Existing Aged-care Mode for the aged unit: % The expected aged-care mode. The expected aged-care mode of the aged is generally the same as the existing aged-care mode, the main change is 13.56% of the aged expect to receive aged-care in aged-care institutions, over 10% more than the aged currently receiving institutional care service for the aged. It indicates that the idea of aged-care is changing and the socialized aged-care demand is increasing. The expected aged-care mode is related, to some extent, to the income of the aged: among the aged expecting institutional care service for the aged, over 85% have low and middle income (monthly income of less than 3,000 Yuan (inclusive)). 百分比 11.86 与å­?女å?Œä½? 13.56 40.68 与è€?伴一起生活，亲å?‹æŽ¢è§† å…»è€?机构养è€? 一个人独居，å­?女或亲å?‹ç»? 33.90 常探视 百分比 Percentage 与å­?女å?Œä½? Live with children 与è€?伴一起生活，亲å?‹æŽ¢è§† Live with spouse, with relatives and friends visits 138 å…»è€?机构养è€? Live in aged-care institution 一个人独居，å­?女或亲å?‹ç»?常探视 Live alone, with frequent children or relatives and friends visits Figure 6-17 The Expected Aged-care Mode for the aged unit: % There are many reasons why the aged are unwilling to receive institutional aged-care service. The traditional idea of living with families ranks the first: 34.04% of the aged choose “it is good to live with familiesâ€?. The consideration of overcharging of the aged-care institution ranks the second (25.53%). Other reasons include poor service, poor living condition, and lack of freedom in the aged-care instruction, and lack of medical rehabilitation service. As a result, most (about 66%) of the aged refuse to receive institutional aged-care service mainly for dissatisfaction with the facilities, conditions, services and charge of the aged-care institutions. Therefore, the improvement of these aspects by the World Bank-financed Project can increase the needs of the aged in the project area for the institutional aged-care service. 其他 6.38 和家人生活在一起挺好 34.04 å…»è€?机构缺ä¹?å¿…è¦?的医疗ã€?康å¤?æœ?务 2.13 在养è€?机构ä¸?自由 8.51 å…»è€?机构æœ?务ä¸?好 14.89 å…»è€?机构生活æ?¡ä»¶ä¸?好 8.51 收费过高 25.53 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 其他 Others 和家人生活在一起挺好 It is good to live with families å…»è€?机构缺ä¹?å¿…è¦?的医疗ã€?康å¤?æœ?务 The lack of necessary medical and rehabilitation service in the aged-care institutions 在养è€?机构ä¸?自由 Lack of freedom in the aged-care institution å…»è€?机构æœ?务ä¸?好 Poor service of the aged-care institution å…»è€?机构生活æ?¡ä»¶ä¸?好 Poor living condition of the aged-care institutions 收费过高 Overcharging Figure 6-18 Reasons Why the aged are Unwilling to Receive Institutional Aged-care Service unit: % 2) The potential impact of the integrated medical and aged-care service project on the aged interviewed 139 According to investigation, some of the aged hospitalized in Traditional Chinese Hospital of Lu An received care from family member or nursing worker, while many are lack of care during hospitalization. The aged interviewed think it is expensive to hire a nursing worker, and it is not a long-term strategy to completely rely on the dependent care; therefore, they are in strong demand for the integrated medical and aged-care service project of Traditional Chinese Hospital of Lu An: in the answer of “Would you like to live in the comprehensive building of the TCM hospital after it is well constructedâ€?, 20.3% of the aged said “very willing, it’s ok to charge moreâ€?, and 27.1% said “willing, as long as the charge is affordableâ€? while 23.7% said “unwilling generally, unless the aged are ill and no available nursingâ€?. 27.1% of the aged said “unwilling, it is unaffordableâ€?, 78.57% of which have low or middle income (monthly income of less than 3,000 Yuan). See Figure 6-19 for details. 1.7 20.3 27.1 27.1 23.7 很愿æ„?，收费贵点没关系 比较愿æ„?，å?ªè¦?收费还能承å?— 一般ä¸?æ„¿æ„?，除é?žè€?人生病没人照顾 ä¸?æ„¿æ„?，ç»?济上无法承担 é?žå¸¸ä¸?æ„¿æ„?，没有必è¦? 很愿æ„?，收费贵点没关系 Very willing, it’s ok to charge more 一般ä¸?æ„¿æ„?，除é?žè€?人生病没人照顾 Unwilling generally, unless the aged are ill and no available nursing é?žå¸¸ä¸?æ„¿æ„?，没有必è¦? Very unwilling, it’s not necessary 比较愿æ„?，å?ªè¦?收费还能承å?— Willing, as long as the charge is affordable ä¸?æ„¿æ„?，ç»?济上无法承担 Unwilling, it’s unaffordable Figure 6-19 The Demand Intention of the Aged towards the Integrated Medical and Aged-care Service Project Unit: % However, only 13.6% and 18.6% of the aged think the project will exert significant and great impact on themselves respectively. It is mainly associated with the lack of understanding of the aged to the project, thus a high proportion (32.2%) of the aged think the project has no influence on themselves, and another 6.8% of the aged have no idea about the influence of the project. Otherwise, it is impossible that over 86% of 140 the aged interviewed support the integrated medical and aged-care service project of Traditional Chinese Hospital of Lu An with the World Bank Loan. Among the aged interviewed supporting the project, 61.4% think that the project can “relieve the burden of their childrenâ€? and 56.8% think that it can “solve the difficulty of getting medical treatment for the agedâ€?. And according to the interview, none of the aged thinks that the project will exert negative impact on themselves. Thus, the integrated medical and aged-care service project can meet the demand of the aged on the combination of medical and health care integrating medical treatment, health care, rehabilitation, aged-care and bring significant potential positive influence to the aged, making the medical treatment, rehabilitation, health care more convenient and economical and practicalâ‘ , and the negative negligible. 6.2.2 The potential impact of the integrated medical and aged-care service project on the family members 1) Basic information of the family members interviewed (a) Gender and age Gender. Of those family members, the male and female account for 47.6% and 52.4% respectively. Age: 23~74, average 45.6. The age of 40-49 accounts for the highest proportion, or 33.33%. 9.52 14.29 19.05 19.05 4.76 33.33 20-29 30-39 40-49 50-59 60-69 70-79 Figure 6-20 Age Structure of the Family Members Interviewed unit: % (b) Educational level and income Educational level. The educational levels of the family members interviewed are in â‘  For the aged requiring hospitalization, physiotherapy, and rehabilitation, the combined medical and health care is more economical than hiring nursing worker or dependent care, but many elderly people have no idea about opportunity cost, hence they are unaware of it. 141 balanced distribution: primary school, junior high school, senior high school or technical secondary school, and junior college and above account for 25%, 30%, 20%, 25% respectively. 15 25 10 20 30 å°?å­¦å?Šä»¥ä¸‹ åˆ?中 高中或中专 大专 本科å?Šä»¥ä¸Š å°?å­¦å?Šä»¥ä¸‹ Primary school and below åˆ?中 Junior middle school 高中或中专 High school or technical secondary school 大专 Junior college 本科å?Šä»¥ä¸Š Bachelor and above Figure 6-21 Educational Level of the Family Members Interviewed unit: % The average monthly income of the family members interviewed is 3,088 Yuan, 41% have an average monthly income of less than 2,000 Yuan and 11.8% have an income of more than 6,000 Yuan. 11.8 23.5 23.5 17.6 23.5 1000元以下 1000-2000å…ƒ 2000-4000å…ƒ 4000-6000å…ƒ 6000元以上 1000元以下 Less than 1,000 Yuan 1000-2000å…ƒ 1,000~2,000 Yuan 2000-4000å…ƒ 2,000~4,000 Yuan 4000-6000å…ƒ 4,000~6,000 Yuan 6000元以上 More than 6,000 142 Figure 6-22 Average Monthly Income of the Family Members Interviewed unit: % There is a weak positive correlation between the monthly income and educational level, while a strong correlation with occupation. The average income ranking from bottom up is peasant, worker, retiree, ordinary corporate employee, administrative body and public institution staff, individual business. Table 6-3 Cross Table of the Income and Educational Level of the Family Members interviewed unit: person More Less 1,000~2,000 2,000~4,000 4,000~6,000 than than Total Yuan Yuan Yuan 6,000 1,000 Yuan Primary school and 6 0 2 0 2 10 below Junior middle 0 6 2 2 0 10 school High school or technical 0 0 4 0 2 6 secondary school Junior 2 0 0 0 0 2 college Bachelor and 0 0 0 6 0 6 above Total 8 6 8 8 4 34 Note: there are 8 default values in this table. (c) Occupation The family members interviewed are engaged in various works, the unemployed or retiree take the highest proportion (35%), administrative body and public institution staff take 20%, individual business takes 15% and peasant takes 15%. In addition, some are workers, ordinary corporate employees and etc. 143 5 ä»– å…¶ 35 员 人 休 5 退 员 或 è?Œ 业 业 15 æ—  ä¼? 户 般 商 一 å·¥ 20 体 员 个 人 5 作 å·¥ 人 ä½? å·¥ å?• 15 府 政 æ°‘ 与 农 业 0 5 10 15 20 25 30 35 40 事 其他 Others 无业或退休人员 The unemployed or retiree 一般ä¼?业è?Œå‘˜ Ordinary corporate employee 个体工商户 Individual business 事业与政府å?•ä½?工作人员 Public institution and government unit staff 工人 Worker 农民 Peasant Figure 6-23 Occupation of the Family Members Interviewed unit: % (d) The cost of the aged In recent three years, the family members interviewed spend average 9,686 Yuan on the aged every year, including 4,538 Yuan of health care expenditure. (e) The interviewed family member’s expectation on the model of aged-care Of those family members interviewed, the home-based aged-care accounts for the highest proportion of 42.9%; 9.5% proportion for the institutional care service for the aged exceeds the average of the whole nation, Anhui province and the local place. Most of the rests are the old couple living alone and have visitors frequently / or occasionally, or a single elderly living alone (widowed or divorced) and have visitors. Of the family members interviewed, 38.1% expect the aged to live with their children, 38.1% expect the aged to live in the reception type aged-care institutions, and 14.3% expect the aged to live in home-based aged-care institutions, supplemented by the community aged-care service. Thus a conclusion can be drew that more than 50% family members expect their elderly people to receive the socialized aged-care, which far exceeds the proportion of socialized aged-care of the current project area. The WB Project will significantly enhance the provision capability and quality of home-based aged-care, community aged-care service and institutional aged-care service in the 144 project area and meet the demand for socialized aged-care. Most of the family members expect their elderly people to receive the socialized aged-care for the main reason that the family members worry that they have no energy and time to care for the aged if the aged are inadequate of self-care ability - two thirds of the family members very or relatively worry about the aged care while only 14.3 never worry about this question. 14.3 9.5 38.1 38.1 与å­?女ä½?在一起 收养性机构养è€? è€?人独居，亲å?‹å®šæœŸæŽ¢çœ‹ 居家养è€?为主，社区养è€?æœ?务中心为辅 与å­?女ä½?在一起 Live with children è€?人独居，亲å?‹å®šæœŸæŽ¢çœ‹ The aged live alone and the relatives & friends regularly visit 收养性机构养è€? Reception type aged-care institutions 居家养è€?为主，社区养è€?æœ?务中心为辅 Home-based aged-care, supplemented by community aged-care service center Figure 6-24 The Interviewed Family Member’s Expectation on the Mode of Aged-care (unit: %) There are two main reasons why the family members do not expect their elderly people to live in the reception type aged-care institutions: one is that they feel it is a good thing to live with the aged (30.77%) and the other is the excessive charges of the reception type aged-care institutions (23.08%). In addition, due to the traditional concept of home-based aged-care, a worry about the good care failing to achieve from the reception type aged-care institutions is also an important reason. The implementation of WB Project (talent cultivation & training for aged-care service, standardized construction for the aged-care, construction for the aged-care institutions, etc.) and construction for the aged-care institutions and the operated supporting policy by the local government can reduce the costs and charges of the aged-care institutions, improve the facilities and service level, eliminate the family member’s concerning for higher charges and lower service level to the institutional care service for the aged and 145 enhance the demand for socialized aged-care. 7.69 23.08 15.38 7.69 30.77 15.38 收费过高 å…»è€?机构æœ?务ä¸?好 担心è€?人的ä¸?到良好照顾 å’Œè€?人生活在一起挺好 在家养è€?是中国传统 其他 收费过高 Overcharging å’Œè€?人生活在一起挺好 A good thing to live with the aged å…»è€?机构æœ?务ä¸?好 Poor service of the aged-care institutions 在家养è€?是中国传统 Home-based aged-care is China’s traditional concept 担心è€?人的ä¸?到良好照顾 Worry about a poor care for the aged 其他 Others Figure 6-25 Reasons Why the Family Members Interviewed Do not Expect their Elderly to Live in the Reception type Aged-care Institutions (unit: %) According to the survey situation, the family member’s expectations on the mode of aged-care have no significant correlation to the elder’s income level, degree of education, number of the brothers and sisters and other factors but have a certain correction to their own age - the older family members prefer the reception type aged-care institutions. 2) The potential impact of the integrated medical and aged-care service project on the family members interviewed The demand for the family members interviewed to the integrated medical and aged-care service project is mainly restricted by three factors: household income, charges of the integrated medical and aged-care service and family member’s time and energy. Therefore, in the answer of “Would you like your elderly to live in the medical care building of Hospital of Traditional Chinese Medicine if it is well constructedâ€?, 9.5% of the family members interviewed showed “very willing regardless of the expensive chargesâ€?, and 42.9% showed “willing as long as an affordable chargesâ€? while 33.3% show “unwilling generally, unless there are no persons to care the agedâ€?. In sum, there is a broad demand space for the family 146 members to the combined medical and aged-care mode as long as the charges are comparatively reasonable (the family members can afford and feel more cost-effective). The integrated medical and aged-care sub-project in the WB Project can meet many family member’s special care demand for the ill elderly. 其他 4.8 é?žå¸¸ä¸?æ„¿æ„?，没有必è¦? 4.8 ä¸?æ„¿æ„?，ç»?济上无法承担 4.8 一般ä¸?æ„¿æ„?，除é?žè€?人生病没人照顾 33.3 比较愿æ„?，å?ªè¦?收费还能承å?— 42.9 很愿æ„?，收费贵点没关系 9.5 0 5 10 15 20 25 30 35 40 45 其他 Others é?žå¸¸ä¸?æ„¿æ„?，没有必è¦? Very unwilling, it’s not necessary ä¸?æ„¿æ„?，ç»?济上无法承担 Unwilling, it’s unaffordable 一般ä¸?æ„¿æ„?，除é?žè€?人生病没人照顾 Unwilling generally, unless the aged are ill and no available nursing 比较愿æ„?，å?ªè¦?收费还能承å?— Willing, as long as the charge is affordable 很愿æ„?，收费贵点没关系 Very willing, it’s ok to charge more Figure 6-26 Aspiration for the Family Members Interviewed to the Medical Care Building of TCM Hospital (%) The integrated medical and aged-care service project can share burdens and solve problems for the family members, help to solve the service demands such as treatment, physical therapy, rehabilitation and life care in the ill elderly, thus having a significant positive effect on the family members. The family members interviewed also have positive attitude: 76.2% think that the integrated medical and aged-care service project of Traditional Chinese Hospital of Lu An has various degrees of positive effect on themselves. Of the family members interviewed, the feeling of “significant impactâ€? and “great impactâ€? accounts for 24% and 27% respectively. 147 ä¸?清楚 5% å½±å“?很大 没有影å“? 24% 19% å½±å“?较å°? 5% å½±å“?一般 10% å½±å“?较大 37% 没有影å“?19% No impact (19%) ä¸?清楚5% Unclear (5%) å½±å“?很大24% Significant impact (24%) å½±å“?较å°?5% Less impact (5%) å½±å“?一般10% Ordinary impact (10%) å½±å“?较大37% Great impact (37%) Figure 6-27 Evaluation of the Family Members on the Impact of the Integrated and Aged-care Project on Themselves The integrated medical and aged-care service project has no significant negative impact on the family members. During the investigation, we find that no family members show the project having negative impact on themselves. 6.2.3 Potential Impact of the Project Transformation and Upgrading of Nursing Home on the Uncared Elderly 1) Overview of the aged interviewed (a) Gender and age Of those elderly people, the proportion of males and females accounts for 66.7% and 33.3% respectively, which shows a significant higher proportion of male than the female. The main reason is that the decision-making power for the social and family affairs on the villages and towns of the project area mainly depends on the male. Of the aged, the minimum age is 51 years old, the maximum is 80 years old and the average age is 68. More than 85% of the aged between 60 and 79, where aged between 60 and 69 account for 48.15% and aged between 70 and 79 account for 37.04%. See Figure 6-28 for details. 148 48.15 50.00 45.00 37.04 40.00 35.00 30.00 百分比% 25.00 20.00 11.11 15.00 10.00 3.70 5.00 0.00 50-59 60-69 70-79 80å?Šä»¥ä¸Š 年龄 百分比% Percentage (%) 80å?Šä»¥ä¸Š Aged 80 and above 年龄 Age Figure 6-28 Age Distribution of the Aged Interviewed (b) Marital status Of those who have spouse account a higher proportion of 59%, followed by the proportion of 26% for elderly without spouse. The divorced and single elderly people account a lower proportion. 4% 11% 26% 59% é…?å?¶å?¥åœ¨ 丧å?¶ å?•èº« 其他 é…?å?¶å?¥åœ¨ Spouse alive 丧å?¶ Widowed å?•èº« Single 其他 Others Figure 6-29 Marital Status of the Aged Interviewed (c) Educational level Cultural levels for most of the aged are low, where those who have primary education and below account for 74.1%, many of them are illiterate; 18.5% have junior middle 149 school education; the number of elderly with junior college and above education are 0. 7.4 18.5 74.1 å°?å­¦å?Šä»¥ä¸‹ åˆ?中 高中或中专 å°?å­¦å?Šä»¥ä¸‹ Primary school and below åˆ?中 Junior middle school 高中或中专 High school or technical secondary school Figure 6-29 Educational Level of the aged Interviewed (d) Income and source The aged with an average monthly income of 1,339 Yuan is significantly less than the city elderly. Wherein, the minimum average monthly income is 200 Yuan, 10,000 Yuan for the maximum. The aged with an average monthly income of 500 Yuan account for the highest proportion (29.6%) and the aged with an average of more than 3,000 Yuan account for the lowest (7.4%). 29.6 30 25.9 22.2 25 20 14.8 百分比% 15 7.4 10 5 0 500元以下 500-1000å…ƒ 1000-2000å…ƒ 2000-3000å…ƒ 3000å…ƒå?Šä»¥ä¸Š 月收入 500元以下 500-1000å…ƒ 1000-2000å…ƒ 2000-3000å…ƒ 3000å…ƒå?Šä»¥ä¸Š 百分比% Percentage (%) 500元以下 Less than 500 Yuan 500-1000å…ƒ 500~1,000 Yuan 1000-2000å…ƒ 1,000~2,000 Yuan 2000-3000å…ƒ 2,000-3,000 Yuan 150 3000å…ƒå?Šä»¥ä¸Š More than 3,000 Yuan 月收入 Monthly income 500元以下 Less than 500 Yuan 500-1000å…ƒ 500~1,000 Yuan 1000-2000å…ƒ 1,000~2,000 Yuan 2000-3000å…ƒ 2,000-3,000 Yuan 3000å…ƒå?Šä»¥ä¸Š More than 3,000 Yuan Figure 6-30 Income of the aged Interviewed There is a significant positive correlation between the income and educational level of the agedâ‘ . The average monthly income of the elderly people who have received education of primary school degree and below, junior middle school, high school or technical secondary school are 882 Yuan, 1,300 Yuan, and 6,000 Yuan respectively. Table 6-4 Cross Table of the Income and Educational Level of the Aged Interviewed (unit: person) Educational level High school Primary Junior or technical Total school and middle secondary below school school Less than 500 14 2 0 16 Yuan 500~1,000 14 0 0 14 Yuan Monthly 1,000~2,000 6 6 0 12 income Yuan 2,000-3,000 4 2 0 6 Yuan More than 3,000 2 0 4 6 Yuan Total 40 10 4 54 55.6% of the aged get their incomes from their children’s alimony, 29.6% from farming or working, annuity, basic living allowance and other channels, and 14.8% from their pension. â‘  Pearson correlation index between the educational level and income of the aged is 0.603 (significance level of 0.001) and the Spearman correlation index is 0.425 (significance level of 0.027). 151 百分比% 14.8 29.6 退休金 å­?女赡养 其他 55.6 百分比% Percentage (%) 退休金 Pension å­?女赡养 Children’s alimony 其他 Others Figure 6-31 Income Source of the Aged (e) Proportion of the aged-care objects guaranteed by the government Among the aged interviewed, the “San Wu peopleâ€?, disabled elderly people/elderly people with dementia with financial difficulty guaranteed or wholly supported by the government account for 14.8% in total. (f) Self-care ability The aged interviewed are highly self-reliant, the proportion of completely and generally self-reliant is 81.5% and 18.5% respectively. (g) Condition of consumption The average monthly consumption of the elderly is 679.1 Yuan, and the ration of consumption and income is 0.51, which shows that there still exists a traditional concept of frugality in household management in the town elderly. The daily consumption expense of the elderly people interviewed accounts for more than 90%, while the average medical care expense is 7.23% of the average monthly consumption expenditures (only 49.08 Yuan). (h) The existing and expected aged-care modes The existing aged-care mode. Currently, most of the aged interviewed are receiving home-based aged-care. Among which, 18.52% of the aged live with their children; 51.85% live with frequent/ occasional visit by their children or relatives and friends; 22.22% live alone (widowed, divorced, single) with visitors. 7.41% belong to “otherâ€? condition (live with their grandchildren). The economics of the transformation and 152 upgrading project area of the township nursing homes (Suzhou City) are relatively backward, most young adults are migrant workers, and the empty-nest elderly people account for a higher proportion. The rural aged-care problem will be highlighted if the self-care ability of the aged decline sharply - during the interview, many elderly people and family members are extremely worried. 7.41 18.52 与å­?女å?Œä½? 22.22 与è€?伴一起生活，å­?女ç»?常探视 与è€?伴一起生活，很少有人探视 一个人独居，å­?女或亲å?‹ç»?常探 视 其他 14.81 37.04 与å­?女å?Œä½? Live with children 与è€?伴一起生活，å­?女ç»?常探视 Live with spouse, with regular children visits 与è€?伴一起生活，很少有人探视 Live with spouse, with seldom visits 一个人独居，å­?女或亲å?‹ç»?常探视 Live alone, with frequent children or relatives and friends visits 其他 Others Figure 6-32 The Existing Aged-care Mode for the aged (%) The expected aged-care mode. There is a big difference between the expected aged-care mode and the existing aged-care mode of the aged: 70.4% expect to receive aged-care in the nursing home. Surprisingly, the existing aged-care mode is the aged “living with their childrenâ€? all expect to receive aged-care from the nursing home and the aged “living with their spouse with frequent visit by their childrenâ€? are 90%. It indicates that the idea of aged-care of the township elderly is significantly changing and the socialized aged-care demand may be sharply increasing. Due to insufficient nurses and difficult to recruit, lacking of incentive mechanism and other factors, the township nursing homes of the existing project area rarely receive the social elderly. Therefore, the socialized aged-care service capability is urgently in need of improvement; otherwise it will be difficult to meet the radically-increased socialized aged-care demand. The transformation and upgrading project of the township nursing homes included in the WB Project is designed to improve the facilities of the nursing home, increase or promote quality of the aged-care service beds of the elderly not 153 enjoying the five-guarantees, significantly enhance the supply capacity of the aged-care service in the township nursing home of the project area, and conform to the variation tendency of many township socialized aged-care service demand of the project area. 11.1 18.5 70.4 与å­?女å?Œä½? 敬è€?院 独居，家人或亲å?‹ç»?常探视 与å­?女å?Œä½? Live with children 敬è€?院 Nursing home 独居，家人或亲å?‹ç»?常探视 Live alone, with frequent family members or relatives and friends visits Figure 6-33 Proportion for the Expected Elderly Mode of the aged (%) The expected aged-care of the aged is related to the income: the aged with a higher income (more than 2,000 Yuan) more tended to receive the aged care form nursing home (> 80%). Because of the unwillingness of the aged to receive the aged care from the nursing home away from their home, a good management and service mode of the nursing home will greatly enhance the interests and demands of the aged while a poor management and service will inhibit their interests and demands. The survey demonstrates that many respondents have negative evaluation on the items such as service quality and living standard of the Beiyangzhai nursing home, so that only 30% of the elderly in Zhenbei Village, Beiyangzhai expect to receive aged-care from the nursing home. There are well facilities, higher management and service level, higher occupancy rate and degree of satisfaction in Fengmiaozhen and Yangtuanzhen nursing homes, but the aged who have not register need to wait in line. Therefore, 94.1% from 4 villages of the two towns expect to receive the aged care from the nursing home. It indicates that the most sensitive factor of the township elderly is management and service level under the existing charge level of the nursing homes. 154 Therefore, the policy of World Bank-financed Project supporting the transformation and upgrading of some well-managed township nursing home can balance the supply and demand of the township institutional care service for the aged. However, there may be a higher uncertainty whether the transformation and upgrading for the township nursing home with a higher bed-vacancy rate, poor management and service level will achieve the expected goal, unless the management and service level of those nursing homes can be effectively improved. 2) Impact of the Project Transformation and Upgrading of Township Nursing Homes on the aged (the aged not received care from the nursing home) There is a strong demand for the transformation and upgrading project of township nursing home in the aged interviewed: in the answer of “Would you like to live in the township nursing homes if its facilities are significantly improvedâ€?, 51.9% and 25.9% showed “very willingâ€? and “willingâ€?, and only 7.4% showed “unwillingâ€? and “very unwillingâ€?. Wherein, all the aged interviewed from the non-Beiyangzhai (4 village from Fengmiaozhen and Yangtuanzhen) said “very willingâ€? and “willingâ€?, 40% of the aged interview wed from the Beiyangzhai said “very willingâ€?, no person said “willingâ€?, and 20% said “unwillingâ€? and “very unwillingâ€?. 3.7 3.7 14.8 很愿æ„? 比较愿æ„? 51.9 一般愿æ„? ä¸?æ„¿æ„? é?žå¸¸ä¸?æ„¿æ„? 25.9 很愿æ„? Very willing 比较愿æ„? Willing 一般愿æ„? Willing generally ä¸?æ„¿æ„? Unwilling é?žå¸¸ä¸?æ„¿æ„? Very unwilling Figure 6-34(a) Would You Like to Live in the Township Nursing Homes If It Is Well Constructed (%) 155 0.00 很ä¸?æ„¿æ„? 10 0.00 ä¸?æ„¿æ„? 10 0.00 一般愿æ„? 40 41.18 比较愿æ„? 0 58.82 很愿æ„? 40 0 10 20 30 40 50 60 70 北æ?¨å¯¨æŒ¯åŒ—æ?‘ é?žåŒ—æ?¨å¯¨æŒ¯åŒ—æ?‘ 很ä¸?æ„¿æ„? Very unwilling ä¸?æ„¿æ„? Unwilling 一般愿æ„? Willing generally 比较愿æ„? Willing 很愿æ„? Very willing 北æ?¨å¯¨æŒ¯åŒ—æ?‘ Zhenbei Village, Beiyangzhai é?žåŒ—æ?¨å¯¨æŒ¯åŒ—æ?‘ Non Zhenbei Village, Beiyangzhai Figure 6-34(b) Would You Like to Live in the Township Nursing Homes If It Is Well Constructed (%) Impact (positive) of the transformation and upgrading of township nursing homes on the elderly not enjoying the five guarantees is significantly positive related to the willingness of the elderly not enjoying the five guarantees living in the nursing home. â‘  18.5% and 44.4% of the aged think the project will exert significant and great impact on themselves respectively, and only 11.1% think the project will exert no impact on themselves. Where 76.5% of the aged interviewed from Fengmiaozhen and Yangtuanzhen think the project will exert significant or great impact on themselves while the aged interviewed from the Beiyangzhai with the impact above only account â‘¡ for 40%. The survey and analysis demonstrate that the positive impact of the transformation and upgrading project of the township nursing homes on the elderly not enjoying the five guarantees will be subject to the management and service level of the nursing homes involved in the Project - Under the condition of higher management and service level of the nursing homes (accepted by the registered and unregistered â‘  The impact herein only includes the positive impact as the organization and expansion project of township nursing homes will generally exert no negative impact on the aged interviewed. â‘¡ Those who think the project will exert significant and great impacts on themselves are usually the aged with strong or great intension to live in the nursing home in future. 156 elderly), the Project will exert significant positive impact on the elderly not enjoying the five guarantees and achieve a strong support and expectation from the aged. Currently, the lower management and service level of some nursing homes in the project area will exert a stronger restriction on the effect of the transformation and upgrading project of the township nursing homes. The sub-project supported by the basis of the diverse aged-care system can partly weaken the restriction, but the restriction needs high attention. ä¸?清楚 11.1 没有影å“? 11.1 å½±å“?较å°? 7.4 å½±å“?一般 7.4 å½±å“?较大 44.4 å½±å“?很大 18.5 0 5 10 15 20 25 30 35 40 45 50 百分比% ä¸?清楚 Unclear 没有影å“? No impact å½±å“?较å°? Little influence å½±å“?一般 General influence å½±å“?较大 Great influence å½±å“?很大 Significant influence 百分比% Percentage (%) Figure 6-35 Evaluation of the Aged Interviewed on the Impact of the Transformation and Upgrading Project of Township Nursing Homes The transformation and upgrading project of township nursing homes will exert no significant negative impact on the elderly not enjoying the five guarantees. No elderly not enjoying the five guarantees felt the negative impact of the Project on themselves. 7. Impact of the Project on Other Stockholders 7.1 Impact of the Project on Civil Affairs Departments at All Levels In the long term, the project goal is consistent with the interest demand of civil affairs 157 departments at all levels, and the overall impact is positive. However, according to the different stages from the preparation to implementation of the Project, the condition is not entire for individuals of the civil affairs departments. Due to a long-term preparation and high demand of the World Bank-financed Project, significant pressure and even troubles have been caused for some civil affairs departments. Director Pan of Civil Affairs Bureau in Lu An City: Director Pan said that the current situation is passive, and it is unclear whether the Project can be completed. 10 million revenues had been reserved from the supporting project of financial supporting funds last year, and funds are also prepared this year, but the funds cannot be used due to the unapproved Project and slow approval of the World Bank-financed Project. It is difficult to do with some events such as the community services for community care service for the aged and home-based aged-care. On the annual meeting of 2015, there occurs an opportunity. Proposal of the deputy to the national people's congress came into legal effect as it was listed as No. 1 proposal. The deputies urge that the government must well complete this Project because the project theme of “Home-Based Aged-careâ€? exactly conforms to proposal of the deputies. However, the Project has been delayed for a long term, we also have lot of pressures to report to the deputies. We learned that many staffs complained the World Bank-financed Project causing their workloads from the survey due to a large number of preparation materials and high demands. They said that they will be the dedicator if the aged and family members, aged-care institutions and society can benefit from the Project. Considering the existing personal and financial systems, neither manpower nor reward can be increased to reduce their working pressures and enhance their initiatives. If the condition exists a long term, the working passion for the staffs of civil affairs department will be influenced inevitably. 7.2 Impact on the Aged-care Institutions Positive impact: 1) the establishment of standardized community-based aged-care service station (or rural nursing home) and government purchasing the aged-care service by the World Bank-financed Project solved the problems of part construction and operation funds of institutions; 2) the provincial-level sub-project can offer help on service standard and talent cultivation for the aged-care institutions; 3) the World Bank can introduces some aged-care institutions in advanced countries and regions for communication and training and enhancing the aged care concept and management level of the aged-care institutions in project area; 4) created fair, just and public market bidding mechanism to meet the interest demand of institutions to 158 project in accordance with the strict bidding and tender procedures. Therefore, all aged-care institutions interviewed express their support for the World Bank-financed Project. Negative impact: some aged-care institutions worry that the poor geographical location of some sites will be not suitable for living of the aged once the standard community sites are constructed. They demand the government to distribute the sites scientifically and do not have to establish a site for every community. In the places having large demand of aged-care, such as big changes for the external environment of dwelling and centralized region of residents, the sites may be constructed a little more than those places with few demands for aged-care, such as industrial area, commercial area. In accordance with both the domestic and international development trend, the social charity organizations and social work institutions will play more and more important roles in the community aged-care services. In particular, this type of organizations take their roots in the community and interact with the original management and service staff of aged-care in the community, forming a force that cannot be ignored. Qiming Social Work Service Center was investigated during the survey in Lu An conducted by the social assessment consulting staffs. Such center is the first professional social work service institution with vigorous support of Lu An Municipal Civil Affairs Bureau and registered in April 2014. Social worker of Qiming Social Work Service Center: At the beginning, I interact with the community to development some activities such as course of silk flowers when there is project. I need to communicate with the community about duration and course contents of the interest-oriented class. However, I found that this is not feasible for no institutional mechanism is formed and the community thinks that our service is of no great importance. The ideal work mode is that the social workers enter and reside in the community. This mode is being promoted and social work service stations have been set up in three communities in two years. We dispatch the workers to the community to develop activities on each Friday or Saturday. It is us who determine the duration and contents of the class and the community depends on us in light of this. The social work service station and the communities are cooperation relationship. The sympathy activities during holiday must be guided by the workers of the community and it takes time for the society to accept the work of social workers. When we visit the residents more frequently, they get to know us and it is good for our work. These need cooperation of the communities. Take Zhuizimiao Community in Gulou Sub-district for example, they did very well in aged-care service 159 and all workers are concurrently provided by the workers of the community. The community has roughly more than forty volunteers. However, they have poor professional skills, did not receive the relevant professional education or training on aged-care service, and thus do not have the qualification for nursing staff in the aged-care service industry. Hence, it requires help of the social workers. We jointly do this, which is the best mode. It is explicitly put forward in the Feasibility Study Report of Lu An Municipal Government’s Procurement of Aged-care Service Items from the Social Force that the government should offer support to help development of the social aged-care organizations. Obviously, this has positive impacts on the social work service center like Qiming and the communities which have good interaction with the social work organizations (including the volunteers in the communities). 7.3 Impact on Other Residents of Communities Aged-care service system has been listed in the testing contents of government. The governments at all levels will focus more on the construction of the aged care, and many community aged-care service stations are constructed under the support of government. Therefore, the implementation of project may exert impacts on other residents of communities due to the occupation over the areas that they can have activities previously, and the impact will be negative if no corresponding compensations are made. In addition, house decoration and civil works during the project implementation will inevitably cause large inflow of the construction workers. In case of mismanagement, the construction workers may engage in illegal sex trade since their physical needs cannot be met and thus become the susceptible group of communicable diseases including AIDS, increasing the risk of developing communicable diseases in the community. 8. Gender Analysis of the aged Care Service Workers This Project conducts a social economic survey on the female aged-care service workers according to questionnaire, intensive interview, panel discussion and other forms. 160 8.1 Overview of the Female Aged-care Service Workers of Project 1) Occupation, age and income According to the analysis of Chapter V, the workers of aged-care institutions are predominantly female with an average proportion of 64.56%. Where female workers in urban community and home-based aged-care institutions account for a higher proportion of 70.83% while the urban reception type aged-care institutions accounts for a lower proportion of 56.52% (See Table 5-1). The survey shows that there is a little difference between the average age of the male and female aged-care service workers in project area, with 47.64 and 44.72 years old respectively. Among the workers, the males aged between 20 and 29 account for the lowest proportion (5.06%), the females aged between 40 and 49 account for the highest proportion (29.11%), and the workers aged 60 above account for a relative higher proportion (16.46%) (See Table 5-2). There exists gender difference for the incomes of the aged-care service workers: the average monthly income of the males and females are 2,607 Yuan and 2,157 Yuan; the monthly income of 71.4% males is more than 2,000 Yuan while females are only 49%. The income difference of males and females is mainly the gender difference of the position and post: nearly 50% of the males have positions while females are only 29.4%; 62.75% of the females engage in the lower income works such as nursing and logistics while males are only 28.57%. 2) Educational level According to the distribution of the educational level from the survey samples, there is a significant difference for the educational level of the investigated between males and females. The females with junior high school below are significantly more than the males, the males with junior high school above are significantly more than the females, and females are slightly higher than the males only on bachelor and above (5.9% and 3.6% respectively). Table 8-1 Distribution of Gender and Educational Level from the Survey Samples Educational level Total 161 High Primary Junior school or Junior Bachelor school and middle technical college and above below school secondary school Male 17.9% 25.0% 32.1% 21.4% 3.6% 100.0% Gender Female 21.6% 33.3% 21.6% 17.6% 5.9% 100.0% Average 20.3% 30.4% 25.3% 19.0% 5.1% 100.0% 8.2 Cognition and Attitude of the Female Aged-care Service Workers to the Project The statistical result of questionnaire indicates that only 19.6% of the affected female workers interviewed never heard of the World Bank-financed Project, 33.3% said “know a littleâ€?, 15.7% said “knowâ€?, 13.7% said “know wellâ€?, and 17.6% said “know muchâ€?. According to the understanding of the Project, the cognition and understanding of the females are slightly more than the males. Table 8-2 Understanding of the Workers to the World Bank-financed Project Do you know the integrated aged-care system in Anhui Province? Know Never Total Know Know well General known much A few Know Known Male 7.1% 21.4% 28.6% 21.4% 21.4% 100.0% Gender Female 17.6% 13.7% 15.7% 33.3% 19.6% 100.0% Average 13.9% 16.5% 20.3% 29.1% 20.3% 100.0% The results show that most females know the impact of the project on themselves. 39.2% said “significant impactâ€?, 25.5% said “great impactâ€?, and the total 64.7% of the two groups is little different from the proportion of 67.9% of males. 162 Table 8-3 How do you think the impact of the diverse aged-care service system established on yourself How do you think the impact of the diverse aged-care service system established on yourself Total Significant Great General No Unknown influence influence influence influence Male 28.6% 39.3% 17.9% 10.7% 3.6% 100.0% Gender Female 39.2% 25.5% 21.6% 9.8% 3.9% 100.0% Average 35.4% 30.4% 20.3% 10.1% 3.8% 100.0% The questionnaire statistics show that working environment and condition (66.7%) and income (47.1%) are the most concerned impact of females, though it is similar to the sequence of the questions concerned by males, the proportion is much larger than the males (60.7% and 32.7% respectively). Table 8-4 Impact Concerned by the Workers Working Worki Opportun Worki Inco environm ng ity of Othe Unkno ng me ent and strengt promotio rs wn hours condition h n 32.1 28.6 3.6 Male 60.7% 3.6% 10.7% 3.6% Gend % % % er Fema 47.1 15.7 5.9 66.7% 7.8% 7.8% 3.9% le % % % 41.8 20.3 5.1 Average 64.6% 6.3% 8.9% 3.8% % % % 8.3 Attitude and Suggestion of the Female Aged-care service Workers to the Project 1) Attitude The statistical results of the questionnaire show that all the workers interviewed support to develop the diverse aged-care service system, which has no difference from the males. The questionnaire results from the nursing homes also support the system. 163 Table 8-5 Attitudes to Develop the Diverse Aged-care Service System Do you believe it is necessary to develop the diverse aged-care service system? Total Very Relatively General necessary necessary Male 85.2% 14.8% 0.0% 100.0% Gender Female 70.0% 26.0% 4.0% 100.0% Average 75.3% 22.1% 2.6% 100.0% Attitude to Reconstruct and Expand the Nursing Homes Table 8-6 Do you support for the reconstruction and expansion of the nursing homes by the World Bank-financed Project Total Very Relatively Generally support support support Male 81.5% 18.5% 100.0% Gender Female 88.2% 7.8% 3.9% 100.0% Average 85.9% 11.5% 2.6% 100.0% 2) Suggestion of females to the Project The survey shows that the order of rehabilitation and health care (76.5%), living supporting facilities (70.6%), recreational facilities (56.9%), other facilities (41.2%), safety and bed facilities (both are 33.3%) ranked by the females is similar to the males in terms of the purpose of the World Bank-financed Project. Table 8-7 What facilities do you think the World Bank Loan should be used to improve? Medical Living rehabilitatio Newspapers Safety Other Recreationa Unknow Beds supportin n and , periodicals facilitie facilitie l facilities n g facilities healthcare and books s s apparatus 39.3 Male 53.6% 46.4% 71.4% 14.3% 28.6% 39.3% 3.6% Gende % r Femal 33.3 70.6% 56.9% 76.5% 27.5% 33.3% 41.2% 5.9% e % 35.4 Average 64.6% 53.2% 74.7% 22.8% 31.6% 40.5% 5.1% % There exists an interesting phenomenon for answer of males on “What kind of talents should be introducedâ€?. On the one hand, most females think that “It is important for the education background and title of talents, as long as they are affectionateâ€?, on the other hand, many people think that “specialists with high education or senior professional title should be introducedâ€?. 164 Table 8-8 Opinions on the Talents Introduced What talents do you think are in the most need of introduction Talents with Education Education high Specialists background background education or with high and title are and title are senior education or not not Total professional Unclear senior important, important, as title, but professional matched long as they without title major is are matched typical affectionate major Male 28.6% 3.6% 7.1% 57.1% 3.6% 100.0% Gender Female 19.6% 3.9% 11.8% 62.7% 2.0% 100.0% Average 22.8% 3.8% 10.1% 60.8% 2.5% 100.0% 8.4 Impact of the Project on the Women in the Project Area 8.4.1 Impact on the Female Aged-care Service Workers in the Project Area The specific performance for the potential impact of the Project on the female aged-care service workers is listed below: 1) To increase economic income Once implemented the Project, a public and private operation mode will be implemented by the community home-based aged-cares and government purchased service, and the rural and urban welfare homes will have ability to receive more social elderly. The specialized integrated medical and aged-care service institutions will also implement new incentive policy to improve the income of the existing aged-care service workers of different levels. 2) To improve working environment and condition The main contents of the Project are improving infrastructures, updating and upgrading aged-care equipment, purchasing decorating materials and other items, most of them significantly improved and beautified the working environment and condition of the workers. There exist increasing and reducing conditions of the labor strength due to the implementation of the Project. After the implementation of the Project, the service objects of the community home-based aged-care, government-financed aged-care service and specialized reception type aged-care institutions will be substantially 165 increased. The labor time and strength of many existing workers will be also increased under the condition of demand exceeding supply for the aged-care service workers. However, the labor strength will be reduced with the application of new equipment, new facilities and new technologies, e.g. wheelchair accessible passage will facilitate the convenient spatial displacement for the semi-disabled elderly people; establishment of information platform and application of intelligent device will help the nurses more timely and conveniently grasp the living condition of the service objects. 3) To increase the opportunity of training and promotion Talent training is an important item of the Project. Sub-project 1 is designed to provide professional training for the aged care nurses, managers and administrative staff of civil affairs department and government, and even provide the professional academic education for the aged-care specialty of institutions accordingly. The high-level training will promote the widespread benefits of the female aged-care service workers at all levels, improve their professional skills and increase their opportunities of promotion. 8.4.2 Influence on potential female aged-care service workers in the project area 1) To provide non-agricultural jobs for female in project area The implementation of the project will bring about more than 7,720 people to be employed whose jobs include general nurses, professional nurses, psychological counselors, therapists, general doctors, physical therapists, information staff and other jobs, most of which are suit for female. 2) To alleviate the household labor burden of women in the project area Due to the traditional thoughts that men work outside to support the family and women take care of the family, women are usually responsible for children rearing and aged-care in China. The implementation of the project will accelerate the trend of socialization of elderly support and alleviate the household labor burden of women. 166 9 Identification of World Bank’s safeguard policies The World Bank aims to alleviate and reduce poverty. At present, all project activities of the bank centers the new proposal that the absolute poverty will be eradicated and the common prosperity will be promoted by 2030. On the one hand, to meet the requirements of the developing countries, the World Bank invests in infrastructure construction and education and health undertakings in backward area in order to promote the local economic development and increase the chances and capability for poor people to achieve common prosperity. On the other hand, the World Bank requires that during the implementation of all investment projects, local vulnerable absolute poverty population and the disadvantaged groups must be fully protected, and the ecology and environment must be protected, too. Therefore, the World Bank has formulated and developed the safety regulations in the past 20 years as the implement policy of the project to help to identify and avoid the negative effect of the project on the local society and environment as soon as possible. If unavoidable, the negative effect should be minimized. The lender and PIU must agree to implement the safety policies formulated by the World Bank before engaging in the World Bank-financed Project. 9.1 Identification and analysis of ethnic minorities 9.1.1 Identification basis According to World Bank's safeguard policy OP4.10, “ethnic minoritiesâ€? refers to the social group who are different from the mainstream society in terms of social and cultural characteristics so that their social status is fragile and they are easy to be discriminated in the development course. Ethnic minorities can be defined according to the different degrees of the following features: (1) They and others believe that they belong to a particular cultural group; (2) Have concentration habitation in the project area or sticking to demesne from their ancestors and relying on the natural resources of the residence area or demesne; (3) Having traditional culture, social and political organization which are different from the mainstream society and culture; (4) Having their own language which is usually different from the official language. 167 9.1.2 Identification method (1) Field investigation. Through the field investigation, we should know the population structure, ethnic composition and economic structure of the project-affected villages. We should also identify the villages of ethnic minorities and know if the ethnic minority lives in compact communities. (2) Data collection and literature review. By collecting the statistical yearbook, statement, municipal annals, county annals and other literatures reflecting the population, nationality, culture and customs of the project area, we should know the characteristics of the ethnic minorities and find out whether they are different from the Han people in such aspects as production and living. (3) Talking with key information person. By talking with the key contact of the principal in National Bureau of Religious Affairs, we should know the types of ethnic minorities, population size, ethnic characteristics and concentrated distribution in project area, and we should also know related projects that are being implemented to promote the development of ethnic minorities. 9.1.3 Identification result Anhui province is where ethnic minorities are scattered. The statistical results show that there are 55 ethnic minorities with permanent population of 395,600, accounting for 0.57% of the total population of the whole province. The Hui nationality, Manchu nationality and She nationality in Anhui province have lived there for generations. Among them, the Hui nationality has the largest population, accounting for 83% of the total population of ethnic minorities in the province and ranking 9th in the whole country. In the province, ethnic minorities are distributed as “big disperser, small centralismâ€?, which means they center in Huaibei district and scatter in regions south of the Yangtze River. In the project area, there are ethnic minorities with the population of 101,300, accounting for 25.33% of the province's minority nationality people and 0.16% of the total population of the project area. Based on the identification of ethnic minorities, workers in social evaluation team, under the cooperation of the various project organizations, has screened the distribution and settlement of ethnic minorities by means of field investigation, literature review and talking with key information person. 168 The results show that there are no concentrated areas for ethnic minorities in the vicinity of the municipal welfare homes and the township nursing homes, and within and around the community. See Table 9-1 for distribution of ethnic minorities in project area. Table 9-1 Population Evaluation of Ethnic Minorities in Project Area Centralized Ethnic Proportion Population residence of Project Han Nationality (ten minorities of ethnic (ten ethnic city/county thousand) (ten minorities thousand) minorities in thousand) (%) project area Anhui 6195.5 6155.6 40 0.64 / province Project area 2280.2 2270.1 0.44 None Lu An city 477.2 474.4 2.8 0.59 None Suzhou city 559.9 557.8 2.1 0.38 None Anqing city 461.2 459.1 2.13 0.46 None Wuhu city 367 365.2 1.8 0.49 None Xuancheng 260.1 258.8 1.3 0.50 None city 9.1.4 Judgment on preparation of ethnic minority development plan Through the identification and screening of ethnic minorities, the results show that: 1) There are small number of ethnic minorities in the project area which is not an area for ethnic minorities; 2) The distribution of ethnic minorities is in the situation of “live together and live scatteredâ€?, and there are no minority areas; 3) All the ethnic minorities are the same as the Han Nationality in the aspects of economic structure, social organization structure, production and living habit, language, social interaction, weddings and funerals and religious belief. They are equal to the Han Nationality in terms of employment, salary, promotion and political election; 4) The ethnic minorities in the project area and the Han Nationality enjoy equal rights of development and can benefit from the project equally. The implementation of the project will not bring any special risks to ethnic minorities. In view of the above, the project doesn’t require the preparation of ethnic minority development plan. 169 9.2 Identification and analysis of resettlement influence 9.2.1 Identification basis According to World Bank’s safeguard policy OP4.12, “displaced personâ€? refers to the group influenced by any of the following conditions: (1) Mandatory â‘ land requisition leads to Relocate or lose their houses; Lose assets or access to gain assets; Lose source of income or means of livelihood no matter whether the involved person has to move to other places; (2) Mandatory limits on the use of statutory parks and protected areas have a negative effect on the lives of displaced persons. 9.2.2 Identification method (1) Field investigation. Through the field investigation, we should know whether the project area is involved in land acquisition and relocation, whether the land is flat, its land attachments and other information. (2) Data collection and literature review. By collecting such documents reflecting project construction as the relevant documentary evidence for land approval (such as pre-examination on the use of land, land-use permit, etc.), the compensation standard for land acquisition and demolition and the feasibility study report, we should know information about the land acquisition and demolition, and identify that there may be displaced person problems in the project. (3) Talking with key informant. By talking with key contact of the principal in PMO, demolition and relocation office, Land and Resources Bureau and other institutions, we should know information about land acquisition and demolition, compensation standard and displaced persons. 9.2.3 Identification result In the project, Xuanzhou District Social Welfare Home needs to be relocated for â‘  “Mandatoryâ€? (or “involuntaryâ€?) means taking action without the consent of the displaced persons or giving them opportunity to choose. 170 rebuilding. Its new address is South Xiaduxincheng, Xuanzhou District (North of Tongjiawan Road, East of Yangzi Road). It has been approved by municipal government in March 20, 2017 and covers an area of 60 mu. At present, related procedures for land acquisition and demolition is ongoing. Other sub-projects involving land acquisition and demolition are as follows: (1) It is planned that Aged-care institution of Traditional Chinese Hospital of Lu An will be built in Lu An city. Materials issued by the Land and Resources Bureau indicate that land assignment was carried out in 2015; (2) It is planned that Aged-care institution of First People's Hospital of Anqing will be built in Anqing city. Materials issued by the Land and Resources Bureau indicate that land assignment was carried out in 2015; (3) It is planned that the headquarters of the aged-care center and community home-based healthcare and aged-care service center will be built in Wuhu city. Materials issued by the Land and Resources Bureau indicate that land assignment was carried out in 2008; (4) The old building named “Paradise of Luckâ€? in the Ningguo Social Welfare Home will be demolished and the comprehensive building-Service Center for the aged will be built instead, which will not involve land acquisition and demolition. See Table 9-2 for land occupation in the project. Table 9-2 Land Occupation of the aged-care institutions in the Project. Is there Land any Land Clearing N Constructio acquisit Acquisit support Rema Name area Land type the site o. n site ion or ion time ing rks (mu) or not not docume nts Comprehen sive health building of Traditional In the Chinese 31.7 mu Chinese 1 Hospital of (21,133 State-owned Yes 2015 Yes Yes 2015 Medicine Lu An m2) Hospital (Rehabilita tion Center of Aged-care) East of Aged-care Xuefu institution Road (206 of First National 2 282 mu State-owned Yes Yes Yes 2015 People’s Highway), Hospital of South of Anqing Weisan Road, West 171 of Jingsan Road, North of Yixiu Avenue (North Huancheng Road) Wuhu HYC Medical Constru 3 State-owned Yes Yes 2008 and Health cted Center Building South Xiaduxinch eng, Social Under Xuanzhou Welfare procedu District Institution Collective-o res of 4 (North of 61.35 Yes in wned land Tongjiawa Xuanzhou acquisit n Road, District ion East of Yangzi Road) Information and data sources: provided by PMOs in various areas. 9.2.4 Judgment on preparation of resettlement plan, due diligence report and policy framework By identifying the displaced persons in the project area, the results show that: The rebuilding of Xuanzhou District Social Welfare Home involves the involuntary resettlement, so the resettlement plan is needed. The old building named “Paradise of Luckâ€? in the Ningguo Social Welfare Home is to be demolished in the institution and the comprehensive building-Service Center for the aged will be built instead, which will not involve land acquisition and demolition. Therefore, due diligence report is not necessary. The headquarters of the community home-based healthcare and aged-care center will be built in Wuhu city. Due to the acquisition time earlier than 2008, due diligence report is not needed. However, the land acquisition time for the two new projects of Lu An and Anqing was in May 2012. Thus, due diligence report for resettlement is needed (See due diligence report). During construction, we should try our best to avoid or reduce the land acquisition and resettlement involved in any project. For involuntary resettlement involved in project construction, Resettlement Policy Framework has been formulated. When the occupation of land, houses and other assets is unavoidable, local PMOs should, in accordance with the requirements of the policy framework, carry out related activities. 172 10. Information disclosure and public consultation 10.1 Information disclosure and public consultation in preparation period Since October 2014, Department of Civil Affairs of Anhui Province has organized a series of investigations and public opinion collections under cooperation with relevant government departments at all levels. During the project preparation, FSR preparation unit, social assessment group preparation unit and EIA preparation unit have publicized and disclosed related information about the project. The fully informed negotiation and public consultation have been also done. The preparation of social evaluation report is based on such public consultation activities as questionnaire, focus group discussion, interview with key informants and stakeholder seminar. 10.1.1 Notification and publicity of information about the project 1) In October 2014, approved by the State Council, National Development and Reform Commission and the Ministry of Finance issued the Notice of National Development and Reform Commission and Ministry of Finance on Use of World Bank Loan for Alternative Project Planning in 2015-2017 (F.G.W.Z. [2014] No. 2284) where the construction project of aged-care service system in Anhui province is listed in the World Bank loans for 2015-2017 Alternative Project Planning. 2) From December 8, 2014 to December 9, 2014, negotiation was done with the World Bank in China, provincial ministry of finance, provincial development and reform commission and each city involved in the project. On the basis of the original project type, government purchased services, elderly healthcare-based tourism, medical institutions for geriatrics and talent training was added, which enriched the project. Besides, the centralized residence-based care service that is difficulty in implementing was reduced. Institutional projects were reduced to 41.1%. 3) From November 17, 2015 to November 25, 2015, the identification delegation for the project loaned by World Bank came to Anhui province for project identification and business training related to the project. Content: 1. discussing the project progress 173 and the feedback to memo after preliminary identification, development goal, results and composition of the project; 2, technical discussion, urban community-based aged-care service, urban home-based aged-care service and voucher, rural nursing home, reconstruction, urban centralized residence-based care service, Internet of Things, project management system at provincial level, monitoring and evaluation systems, capability evaluation of the aged and standard system construction; 3. business training of World Bank, safety policy and its evaluation and trusteeship requirements. 4) From April 25, 2016 to April 29, 2016, the preparation team for World Bank-financed Project came to Anhui Civil Affairs Bureau for technical discussion in order to know the project progress after the project was identified by Department of Civil Affairs of Anhui Province and PMO and PMO of various cities, and to know the updated changes of the project scope and the institutional arrangement. Project cycle, results and framework, and activity content of the project were discussed with Department of Civil Affairs of Anhui Province and PMO, and PMO of various cities. Technical discussions were done and consensus was achieved so as to go to the next step of the project schedule. 5) On May 25, 2016, Elena Glinskaya and Zhangshuo, the project manager, talked about the integrated medical and aged-care service projects in Lu An city, Anqing city and Wuhu city and further learned the total loan amount, fund allocation and reimbursement subject of Traditional Chinese Hospital of Lu An, First People’s Hospital of Anqing and Wuhu Jinhui Co., Ltd. 6) On January 23, 2017, Department of Civil Affairs of Anhui Province conducted an open bidding for the feasibility study report, social impact assessment and environmental impact assessment of the project. 7) From April 5, 2017 to April 7, 2017, PMO held another talks with the World Bank team to determine the final construction content and procurement, and related financial arrangements of the project. 8) From June 19, 2017 to June 22, 2017, the meeting for pre-evaluation was held in Hefei, Anhui province. 10.1.2 Field investigation 1) From April 8, 2015 to April 10, 2015, the technical delegation for the project 174 loaned by World Bank came to Anhui Province for field survey and talks about the project preparation. On the morning of April 8, 2015, the delegation arrived at Xinqiao airport and then went to Qianshan County, Anqing City. After survey of the project in Qianshan County in afternoon, they went to Anqing City. On the morning of April 9, 2015, they conducted a field survey of the project and held a talking in Anqing City. On the afternoon of the same day, they visited the Wuhu City. On the morning of April 10, 2015, they held a meeting with some project units after returning to Hefei City from Wuhu City. On the afternoon, they made a feedback to the survey activity with the Department of Civil Affairs of Anhui Province, Development and Reform Commission and Ministry of Finance. 2) From June 2, 2015 to June 6, 2015, World Bank preliminary identification group visited Suzhou City, Xuancheng City (Ningguo city, Xuanzhou District and Jing County), Tongling City and Lu An City. The group held a meeting with local civil affairs department and representatives of the proposed project site. After visiting each project site, the group met with the provincial finance department and the provincial PMO for a concluding meeting. 3) From November 17, 2015 to November 25, 2015, the identification delegation for the project loaned by World Bank came to Anhui Province for project identification and business training related to the project. At the same time, they visited the public-sponsored and private-operated aged-care institution and non-government sponsored aged-care institution in Hefei City, discussing the current situation of aged-care services by introducing social force in Anhui province (home-based, community-based, institution-based, etc.) 4) From May 30, 2016 to June 2, 2016, WB technical delegation came to Anhui Province again to promote the project construction of aged-care service system. The expert panel led by Elena Glinskaya, the project manager of World Bank, conducted a field survey in Xuanzhou City and Wuhu City from May 30 to May 31, 2016. 5) From December 18, 2016 to December 19, 2016, WB expert panel conducted a field survey in the project sites of embedded elderly healthcare service in Wuhu City. 6) From March to April 2017, the social assessment preparation unit carried out a field survey in the project area and visited the communities involved in the project. In villages and towns, it told the aged-care institutions, aged-care service workers and the aged involved in the project (and their family members) about the general information of the project, and asked for their suggestions on the implementation of 175 the project that were recorded faithfully. 7) From June 28, 2017 to July 3, 2017, the social assessment group preparation unit came to Lu An and Suzhou City again for fully and preliminarily informed public consultation oriented to the aged and their family members who didn’t accept the service from aged-care institution, and collected their opinion on the project. 10.1.3 Questionnaire 1) From March 1, 2017 to March 17, 2017, the social assessment preparation unit conducted a questionnaire survey on 14 districts and counties of 5 cities in the project area, including: a) the questionnaire survey on workers from 23 aged-care institutions (community-based aged-care service center, community aged-care service station, nursing home, welfare home, etc.). A total of 158 pieces of questionnaires were collected with an effective rate of 100%; b) the questionnaire survey on the aged from 22 aged-care institutions and their family members. A total of 172 pieces of questionnaires were collected with an effective rate of 100%. 2) During June 28 to July 3, 2017, the aged not receiving relevant aged-care service and their family members in one hospital (Traditional Chinese Hospital of Lu An, total 128 elderly people and family members are visited and 118 effective questionnaires are returned), two communities (Renmin Xincun Community in Zhongshi Street, Jin’an District and Qing’an Community in Gulou Street, Yu’an District, Lu An City, total 42 elderly people and family members are visited and 42 effective questionnaires are returned), three villages & towns (Zhenbei Village, Beiyangzhai Town, Yongqiao District, Suzhou City, Gaozhai and Houzhu villages, Fengmiao Town, Lingbi County, Suzhou City and Qiumiao and Hongguang villages, Yangtuan Town, Lingbi County, Suzhou City, total 54 elderly people are visited and 54 effective questionnaires are returned) in the project area (Lu An and Suzhou cities) are subject to questionnaire. 10.1.4 Interview with key informants From March to April 2017, the social assessment preparation unit had an interview with 38 key informants including workers from the civil affairs department, aged-care office and aged-care institution, workers, community service worker and township 176 heads in order to collect their suggestions on the project, mainly focusing on how to optimize the project via social management framework. 10.1.5 Depth interview From March to April 2017, the social assessment preparation unit had a depth interview with a total of 25 people in 23 aged-care institutions in the project area (5 cities). The interview aimed to collect the suggestions of the involved people on the design and implementation of the project, and to find the influence of the project on them and the possible risks. Meanwhile, the social assessment preparation unit had a depth interview with a total of ( ) workers and the aged receiving care in 23 aged-care institutions in the project area. The main purpose of the interview was to know their opinions on the project, opinions and suggestions on the establishment of comprehensive aged-care system, and requirements and expectations on the project. 10.1.6 Focus group symposium From March to April 2017, the social assessment preparation unit held 45 symposiums. Among them: a) 15 were for aged-care service workers with total participants of 120, focusing on their opinions and suggestions on the establishment of the diverse aged-care system, their understanding for the project, and their requirements, opinions and suggestions on engaging in the project. b) 15 were for the aged receiving care with total participants of 107, focusing on their opinions and suggestions on the establishment of the diverse aged-care system, their understanding for the project, their requirements, opinions and suggestions on engaging in the project, and the possible influence on them caused by the implementation of the project. (See picture 3-4) 10.2 Results of public consultation 10.2.1 Cognition and evaluation of aged-care service workers on project 1) How well do aged-care service workers know the project and how to know 177 Aged-care service workers in the project area don’t know well about the project. 30.38% people know the project well, but 29.11% people know little and 20.25% has never known. See Figure 10-1 for details. 13.92 20.25 16.46 29.11 20.25 很了解 比较了解 一般 了解一点 没å?¬è¯´è¿‡ 很了解 Know much 比较了解 Know well 一般 General 了解一点 Know little 没å?¬è¯´è¿‡ Never know Figure 10-1 How well do aged-care service practitioner know the project (%) There are some differences in the knowledge about the project by aged-care service workers in aged-care institutions of different types: workers in urban reception type aged-care institutions know the project best and 56.52% people know the project well; workers in township reception type aged-care institutions know the project least and less than 10% people know the project well. Besides, the knowledge about the project of aged-care service workers is positively correlated with their educational level. Workers who hold administrative post know more about the project than those who don't. Aged-care service workers know the project mainly by their acquaintances (39.68%), Internet (33.33%) and TV (20.63%). 2) Attitudes of aged-care service workers to project The surveyed aged-care service workers believe that this project has a significant positive effect on them and has little or no negative impact. Therefore, aged-care service workers in the project area support the project very much with 85.9% and 11.54% “quite agreeingâ€? and “well agreeingâ€? on the project and no one objects to the project. 178 2.56 11.54 85.90 很赞å?Œ 比较赞å?Œ 一般赞å?Œ 很赞å?Œ Very support 比较赞å?Œ Relatively support 一般赞å?Œ Generally support Figure 10-2 Attitudes of aged-care service workers to project 3) Cognition of aged-care service workers on diverse aged-care service system The aged-care service workers in the project area all have an understanding of the diverse aged-care service system. Among them, 58.23% people know the diverse aged-care service system well and only 2.53% people have never known the system. See Figure 10-2 for details. There are significant differences in the knowledge about the diverse aged-care service system by aged-care service workers in aged-care institutions of different types: workers in urban community-based and home-based aged-care institutions know the system best, workers in urban reception type aged-care institutions know the system less and workers in township reception type aged-care institutions know the project least. Workers in urban community-based and home-based aged-care institutions all have heard of the diverse aged-care service system and 83.33% of them know the system well; 65.22% of workers in urban reception type aged-care institutions know the system well; only 34.38% of workers in township reception type aged-care institutions know the system well. There are significant differences in the knowledge about the diverse aged-care service system by the aged-care service workers of different educational levels. Educational level is positively correlated with the knowledge about the diverse aged-care service system. Workers reaching and under a primary school education, secondary school education, high school or technical secondary education, junior college education, 179 undergraduate education or above who know the system well account for 37.5%, 50%, 60%, 80% and 100% respectively. 2.53 17.72 21.52 21.52 36.71 很了解 比较了解 了解一些 了解一点 没å?¬è¯´è¿‡ 很了解 Know much 比较了解 Know well 了解一些 Know a little 了解一点 Know little 没å?¬è¯´è¿‡ Never know Figure 10-3 How well do aged-care service practitioner know the diverse aged-care service system (%) 4) Attitudes of aged-care service workers to establishment and management of the diverse aged-care service system The aged-care service workers in the project area all think it is necessary to establish and manage the diverse aged-care service system. Among them, 75.32% people think it is “very necessaryâ€? and 22.08% people think it is “relatively necessaryâ€?. Therefore, the aged care workers in the project area support the establishment and management of the system very much. 2.60 22.08 75.32 很必è¦? 比较必è¦? 一般必è¦? 很必è¦? Very necessary 180 比较必è¦? Relatively necessary 一般必è¦? Generally necessary 10-4 Necessity evaluation on the diverse aged-care service system by aged-care service workers (%) 5) Suggestions of aged-care service workers on project Because of the big difference in buildings, facilities and workers in various aged-care institutions, aged-care service workers has proposed some suggestions on the concrete implementation of the project according to the requirements of their own aged-care institutions. More than 40% people hope the capital of the project can be mainly used to improve living facilities and recreational facilities. Those who hope the capital can be used to add or improve healthcare & physical therapy facilities, train aged-care service workers, reform buildings and environment, add or improve beds account for 18.6%, 14%, 11.6% and 9.3% respectively. 10.2.2 Cognition, attitudes and requirements of the aged receiving care on the project 1) The cognition of the aged receiving care on the project The survey shows the aged receiving care in the project area know little about the project: only 3.7% knows the project well, 33.33% knows little and 54.32% have never heard of the project (See picture 10-4). Among the aged receiving care and knowing something about the project, no less than 90% knows the project via two channels: hearing of from others (mainly from the workers in aged-care institutions) and learning from TV. 1.23 2.47 8.64 54.32 33.33 很了解 比较了解 一般 了解一点 没å?¬è¯´è¿‡ 181 很了解 Know much 比较了解 Know well 一般 General 了解一点 Know little 没å?¬è¯´è¿‡ Never know Figure 10-5 How well do the aged receiving care know the project (%) 2) The attitude of the aged receiving care to the project The survey shows that the aged receiving care generally express a high degree of approval after the investigators describe the contents of the project: 74.07% are “strongly approve of" the project and 19.75% are “comparatively approve ofâ€? it, reaching up to 93.83% in total (see Figure 10-5). 6.17 19.75 74.07 很赞å?Œ 比较赞å?Œ ä¸?赞å?Œ 很赞å?Œ Very support 比较赞å?Œ Relatively support ä¸?赞å?Œ Disapprove Figure 10-6 The attitude of the aged receiving care to the project Among the aged in township reception type aged-care institutions who are investigated, 88% are “strongly supportive ofâ€? the project and 12% are “comparatively supportive ofâ€? it, with approval degree reaching up to 100%, which shows that the aged in township reception type aged-care institutions quite expect to improve the buildings and infrastructure of the institutions they are in. 6.29% and 11.11% of the aged receiving care respectively from the urban reception type aged-care institutions and urban community-based and home-based aged-care institutions are not supportive of the projectâ‘ . 3) The expectation of the aged receiving care to the project â‘ The aged who are not supportive the project mainly come from the community-based and home-based aged-care institutions in Lu An and the reasons are unclear. 182 From the Table 10-6, it is shown that the aged receiving care from different types of aged-care institutions have both the same and different expectations on what needs to be done with the project fund. There are two similar expectations: (1) it is most desirable for the project funds to be used to purchase or upgrade the living facilities, especially in the township reception type aged-care institutions where 68% of the aged receiving care hope that the project funds will be used to improve the living facilities of the nursing home or welfare home2; (2) neither wants the project funds to be used to purchase or upgrade the beds mainly because: the aged receiving care in rural area have very low requirement for beds and the vacancy rate of rural reception type aged-care institutions is relatively high; the beds of some urban reception type aged-care institutions are much better than those of rural aged-care institutions and the bed supply falls short of demand, but the aged surveyed don’t have to worry about the lack of beds; urban community-based and home-based aged-care institutions mainly provide short-term care and other non-long term care services, and the short of beds will not happen in short term as this type of aged-care has not opened the market yet. There are four differences in terms of expectations: (1) more than 20% of the aged in urban community-based and home-based aged-care institutions think that the project funds mostly need to be used to effectively cultivate and train the aged care personnel as well as purchase or upgrade recreational facilities, while only a very small portion of the aged in other two types of aged-care institutions hold this opinion; (2) about 24% of the aged in urban and rural reception type aged-care institutions think that the project funds mostly need to be used to build or rebuild the houses1, while none of the aged in urban community-based and home-based aged-care institutions shares this view; (3) 17.24% of the aged urban reception type aged-care institutions hold the opinion that the project funds mostly need to be used to purchase or upgrade the healthcare and physiotherapy facilities while few of the aged in other two types of institutions hold this view; (4) 10.34% of the aged in urban community-based and home-based aged-care institutions think that the project funds need to be used to purchase or upgrade environmental facilities while none of the aged in other two types of institutions shares this view. 2 The upgrading subproject has included 35 rural reception type aged-care institutions of Suzhou where the living facilities are generally old or lacking, and the barrier-free facilities, bath facilities, recreational facilities, bathrooms, kitchens and other facilities need to be purchased or transformed and upgraded. 1 The aged who hold this view live in old and shabby aged-care institutions where there is leakage of rain and potential safety hazard and some of which are even dangerous buildings that need to be rebuilt. 183 Table 10-1 The Expectation of the Aged Receiving Care on the Project Unit: % Type of the aged-care institutions Urban Urban Township community-base reception reception Average d and type type percentag home-based aged-care aged-care e aged-care institutions institutions institutions Effective cultivation and training 22.22 6.90 0.00 9.88 aged-care personnel Purchase or upgrade 44.44 41.38 68.00 50.62 living facilities Purchase or upgrade healthcare and 3.70 17.24 0.00 7.41 physiotherapy What mostly facilities needs to be Purchase or upgrade 22.22 0.00 0.00 7.41 done with recreational facilities the project Purchase or upgrade 0.00 0.00 4.00 1.23 funds beds Improve aged-care the environment of 0.00 10.34 0.00 3.70 institution Build or rebuild 0.00 24.14 24.00 16.05 houses Others 7.41 0.00 4.00 3.70 Total 100.00 100.00 100.00 100.00 10.2.3 The attitude and understanding of the aged without care and their family members to the project 1) The cognition and attitude of the aged interviewed to the integrated medical and aged-care service project The cognition of the aged interviewed on the integrated medical and aged-care service project. Because the implementation party (Traditional Chinese Hospital of Lu An) cannot vigorously promote the project as it is still under preparation, the aged interviewed have very low cognition of the integrated medical and aged-care service project of the hospital. 74.6% of the aged have “never heard ofâ€? the project, 5.1% are “know wellâ€? and 8.5% “know a littleâ€? about it, and none of them “knows muchâ€? about the project. 184 5.1 8.5 11.9 比较了解 了解一些 了解一点 从没å?¬è¯´è¿‡ 74.6 比较了解 Know well 了解一些 Know a little 了解一点 Know little 从没å?¬è¯´è¿‡ Never heard of Figure 10-7 The Aged’s Understanding of Integrated Medical And Aged-Care Service Project Unit: % The attitude of the aged interviewed to the integrated medical and aged-care service project. Regarding the question “Do you think it is necessary to build the comprehensive building of medical and aged-care combination in Traditional Chinese Hospital of Lu Anâ€?, only 10.34% of the aged clearly express “not necessaryâ€? while the percentage of elderly answering “very necessaryâ€? is 27.59%, same to those answering “relatively necessaryâ€?. This shows that most of the aged support the integrated medical and aged-care service project of Traditional Chinese Hospital of Lu An. 15.52 27.59 10.34 é?žå¸¸å¿…è¦? 比较必è¦? 有点必è¦? 没必è¦? ä¸?清楚 18.97 27.59 é?žå¸¸å¿…è¦? Very necessary 185 比较必è¦? Relatively necessary 有点必è¦? A little bit necessary 没必è¦? Not necessary ä¸?清楚 Unclear Figure 10-8 The Aged’s Judgment over the Necessity of Integrated Medical and Aged-care Project Unit: % 2) The cognition and attitude of the family members interviewed to the integrated medical and aged-care service project The cognition of the family members interviewed to the integrated medical and aged-care service project. 52.4% of the family members interviewed have never heard of the project, 28.6% know much or know well about the project and the major channel of learning about the project is “mentioned by othersâ€?. Considering that the Traditional Chinese Hospital of Lu An hasn’t vigorously promote the project, it is shown that the family members interviewed have paid close attention to this kind of project with 47.6% of them having different level of knowledge of the integrated medical and aged-care service project. The attitude of the family members interviewed to the integrated medical and aged-care service project. 90% of the family members interviewed think it is necessary to build the caring building of Traditional Chinese Hospital of Lu An while only 5% of them think it is unnecessary. The percentages of “very necessaryâ€? and “relatively necessaryâ€? are 55% and 25% respectively. ä¸?清楚 没必è¦? 5% 5% 有点必è¦? 10% é?žå¸¸å¿…è¦? 55% 比较必è¦? 25% ä¸?清楚5% Unclear (5%) 没必è¦?5% Not necessary 5% 有点必è¦?10% A little bit necessary 10% 比较必è¦?25% Relatively necessary 25% é?žå¸¸å¿…è¦?55% Very necessary 55% 186 Figure 10-9 The Evaluation of Family Members Interviewed on the Necessity of the Caring Building of Traditional Chinese Hospital of Lu An(%) Most of the family members interviewed think it is necessary to build it mainly because it can relieve the burden of the children (76.19% choose this option) and solve the problem of the difficulty of the aged in receiving medical treatment (52.38% of the family members interviewed choose this option). This is relatively in line with the idea of the aged. When the aged are sick, especially when there is sharp decline of self-care ability due to the sickness, many family members are plagued by the caring of the aged as it is expensive to employ a nursing worker and they themselves do not have enough time and energy. 其他 4.76 能æ??供更好的æœ?务 14.29 能å‡?轻儿女的负担 76.19 解决è€?人看病难问题 52.38 ä¸?为床ä½?排队 19.05 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 其他 Others 能æ??供更好的æœ?务 Provide better services 能å‡?轻儿女的负担 Relieve the burden of children 解决è€?人看病难问题 Solve the problem of the difficulty in receiving medical treatment for the aged ä¸?为床ä½?排队 Don't need to queue for beds Figure 10-10 Why the Family Members Interviewed Think it is Necessary to Establish the Caring Building of Traditional Chinese Hospital of Lu An (%) 3) The cognition and attitude of the aged interviewed to the upgrading project of township nursing homes The cognition of the aged interviewed of the upgrading project of township nursing homes. China’s villages are an acquaintance society where the information spreads fast. The World Bank-financed Project has been prepared for many years and the upgrading project of township nursing homes has early been known to everybody. 187 Therefore, the aged interviewed have a certain understanding of the project, but just a few are very familiar with the project, accounting for only 3.7%. 3.7 40.7 55.6 é?žå¸¸äº†è§£ 比较了解 了解一些 é?žå¸¸äº†è§£ Know much 比较了解 Know well 了解一些 Know a little Figure 10-11 The Understanding of the Aged Interviewed of the Upgrading Project of Township Nursing Homes The attitude of the aged interviewed to the upgrading project of township nursing homes. The vacancy rate of beds in some nursing homes run quite well is extremely low and the aged even queue for living in these nursing homes. In the investigation, many of the rural elderly people interviewed quite worry about their opportunity of being received by the local nursing homes because most of the beds there are only for the aged in the “households enjoying five guaranteesâ€? and the beds for other elderly people are extremely inadequate. The World Bank provides loan for the upgrading of local township nursing homes, which undoubtedly wins the recognition and support of the vast number of elderly people. In the towns covered by the project, the vast majority of the aged think it necessary to upgrade the township nursing homes. In terms of the question “Do you think it necessary to improve the facilities of township nursing homesâ€?, 48.1% and 44.4% of the aged interviewed think it “very necessaryâ€? and “relatively necessaryâ€? respectively. The suggestions of the aged interviewed for the use of World Bank loan. Regarding the question of “Where do you think the World Bank loan should be mainly usedâ€?, the top three answers are “build or expand reception type aged -care institutionsâ€? (63%), “aged-care facilitiesâ€? (48.1%) and “cultivate aged-care personnelâ€? (37%). In addition, a few of the aged choose “construct community care service for 188 the aged sitesâ€? and “improve the internationalization level of aged-careâ€?. This indicates that all the sub-projects of World Bank-financed Anhui Aged-care System Project are supported by some of the aged. Comparatively speaking, the aged in the towns covered by the project support the construction or expansion of reception type aged-care institutions the most. 10.2.4 Implement the public consultation plan In the implementation and operation of the project, the mechanism for public consultation should be established and improved to ensure the smooth progress of the project and the full play of the benefits, minimize or avoid the potential negative influence to the utmost, and achieve sustainable development of the project. The PMOs at each level organize the community service sites, the entrusted aged-care institutions and township nursing homes to allow the aged-care service workers, the aged receiving care and their family members to participate in the information disclosure, project implementation and supervision of the project, thus improving the degree of cognition and participation of the masses, strengthening their awareness of participating in public affairs, and boosting the smooth implementation of the project. Table 10-3 shows the public consultation plan in implementation and operation period of the project. 189 Table 10-3 Action schedule for public consultation Project period Participating activities Content of activity Mode of activity Involved parties Organization in Remarks charge 1) It is necessary to erect a board in the construction of civil works 1) Plenary meeting of community 2) The service sites, nursing homes, residents caring centers and welfare homes 2) Meeting of representatives of 1) PMO Assistance of Information disclosure receiving World Bank loan need to community residents 2) Construction PMO and relevant and publicity display a signboard 3) Community residents institution construction institutions 3) Timely publish the progress of participating in the implementation 3) Community residents institution (town/street) World Bank-financed Project through 4) Internal meeting of construction various media and information platform. institution 4) Hold seminars (The World Bank - PMO) 1) PMO Assistance of Community-based and 1) Recruit and train new employees 1) Hand out training manuals 2) The aged-care relevant home-based care service 2) Organize and train volunteers 2) Training session institutions in community PMO, PIU institutions for the aged 3) Assist in other community activities 3) Publicity activities 3) Relevant training (town/street) institutions 1) Recruit and train new employees 1) Hand out training manuals 1) PMO Assistance of 2) Organize and train volunteers 2) Training session 2) Nursing home relevant Nursing home 3) Do well in the transition work 3) Publicity activities 3) Relevant training PMO, PIU institutions during the implementation and strive for institutions (town/street) the support of staff and the aged. 1) Recruit and train new employees 1) PMO Assistance of 2) Organize and train volunteers 1) Hand out training manuals 2) Welfare home relevant Welfare home 3) Do well in the transition work 2) Training session 3) Relevant training PMO, PIU institutions Implementation during the implementation and strive for 3) Publicity activities institutions (town/street) stage the support of staff and the aged. 1. PMO Establish a 2. Monitoring and Assistance of participation-based 1. Internal supervisory mechanism Interview, symposium and evaluation institution PMO, and relevant monitoring and 2. External independent monitoring questionnaire survey 3. Employees in the monitoring and institutions evaluation mechanism and evaluation aged-care institutions evaluation institution (town/street) 4. The aged receiving care 1) Print the “Project Complaint Formâ€? and hand out in the communities influenced by the project to make it convenient for the residents to give their opinions. 2) The PMO at each level should 1 PMO assign a specific officer to be in 2. Relevant institutions charge of complaint acceptance. (town/street) Assistance of Complaint Establish the grievance mechanism of the 3) Before the project starts, the 3. Community and PMO relevant project. residents in the communities covered employees at the aged-care institutions by the project should be informed of institutions (town/street) the address, phone number, fax 4. The aged receiving number and email address of the care PMO and the officer in charge of complaint acceptance. 4) The communities and PMO at each level should collect the opinions and suggestions at any time. 190 10.2.5 Grievance mechanism During the preparation, implementation and operation of the project, the community residents, and the aged and employees of aged-care institution covered by the project can complain if they meet any problems or they are dissatisfied with the project. Here is the grievance mechanism: Stage 1: The PMO at each level should assign a specific officer to be in charge of dealing with the complaints of the community residents, and the aged and employees of aged-care institution covered by the project; before the project starts, the PMO in the provincial, municipal and county (district) level should inform the community residents, and the aged and workers of aged-care institution covered by the project of the name, address, phone number, fax number and email address of the officer in charge of complaint acceptance; the PMO at each level should update the information related to complaint in every possible way and notice the relevant parties in time if the officer in charge of complaint acceptance has been changed. Stage 2: Residents (villagers) of the project area, the aged and workers in the aged-care service institutions report to the community committee (village committee) orally, in writing, by telephone or mails. If it is oral complaint, the community (village) committee should treat it and make written record. The community (village) committee should reply within 15 working days and solve the complaints (the aged and workers in the aged-care service institution directly report to the aged-care institutions or directly submit their grievance to the county (district) PMO, municipal PMO and PPMO level by level). Stage 3: If residents/villagers of the project area are not satisfied with the results of stage 2, they can submit their grievance to the county (district) PMO, municipal PMO and PPMO level by level after receiving the results. The PMO of various levels will receive the complaints and appeals of the residents/villagers, the aged and workers in the aged-care service institutions. If it is oral grievance, the PMO of corresponding level will deal with it and make written record. The management institutions should make decisions within 15 working days. Stage 4: If residents/villagers or the aged and workers in the aged-care service 191 institutions refuse to accept the result of stage 3, they can institute an action to the local People’s Court for decision in accordance with Civil Procedure Law of the People’s Republic of China. Complainant (residents/villagers in the project area, the aged and workers in the aged-care service institutions Report to the community committee (village committee) or aged-care service institutions orally, in writing, by telephone or mails (the aged and workers in the aged-care service institution can directly report to the superior management institutions County (district) Municipal PPMO PMO PMO Based on the complaints Directly deal Require the Report to the Dealt by the with it subordinate superior PMO Court department to deal with it Opinions and results Grievance procedures Treatment procedures Feedback procedures Figure 10-12 Flow Chart of Grievance Mechanism 192 11. Social management plan and implementation 11-1 Social management plan In order to promote the realization of project benefits and goals and on the premise of the full discussion with such major stakeholders as the civil affairs department, the employees and the aged in the aged care sites and aged-care institutions covered by the project as well as the family members of the aged, the social judgment group has put up with some measures to relieve and avoid risks regarding the possible major social impacts and risks which are identified on the basis of the field survey and data analysis, and are relevant to the design and implementation of the project, and may affect the development goals of the project. The measures mainly involve the following aspects: 11.1.1 Reasonably arrange the spatial location of the aged care sites in community The layout of standard elderly not enjoying the five guarantees care sites should be planned reasonably. In the places where the demand for aged-care is large, the sites may be constructed a little more, while in the places where the demand for aged-care is small, such as industrial area, commercial area, the sites might be less. 11.1.2 Reduce the workload of government staff Hire experienced experts or expert team as soon as possible to effectively reduce the workload of government staff. 11.1.3 Reduce the negative impact of the project on aged-care service workers The implementation of the project involves civil engineering, government's purchasing healthcare service, and training of new employees, which may increase the workload of some existing staff in nursing homes, welfare homes and social aged-care institutions. Suggestions: 193 1) Formulate the transition plan for the implementation period of the project, eliminate the environmental impact and potential risks during construction, and reasonably arrange the work of staff and the transition of the aged; 2) Develop talent motivation and training programs as soon as possible to address the need for human resources during the implementation and operation of the project; 11.1.4 Reduce the negative impact of the project on the aged 1) Formulate temporary transition plan for the construction period to help the aged to adapt to the new environment as soon as possible and to reduce the environmental impact and potential risks during the construction; 2) Deliberate the change of service price. 11.1.5 Reduce the negative impact on other residents in community 1) The existing community activities can’t be weakened. When the conditions permit, the community place for activities should be of multi-purpose. 2) The construction unit is required to strengthen publicity and training on public sanitation and health knowledge to the construction workers, especially the migrant construction workers and set free-of-charge condom distribution or automatic condom sales facilities in the construction site. Meanwhile, the health department and maternal and child health department in the project area provide equipment support and technical guidance to strengthen the publicity on prevention and control of AIDs in the project area, especially the publicity in the rural areas; take full advantage of newspapers, broadcast, TV and other traditional media on the basis of pasting the post and the catch-phrase, distributing the leaflets and holding AIDs-prevention lectures, expand the publicity channels of new media such as Microblog, WeChat and SMS and carry out publicity on knowledge of AIDs and education on risks of communicating AIDs to popularize the knowledge of AIDs prevention and control and let the villagers/residents in the project area know the harm of AIDs and master the prevention knowledge, creating a good social environment for the AIDs prevention and control. 194 11.1.6 Reduce the resettlement influence of the project Formulate the “Resettlement Action Planâ€?. 11.1.7 Establish the grievance mechanism During the preparation, implementation and operation of the project, the complaint channel should be established to provide people affected by the project with the opportunity to complain when they meet any problems or they are dissatisfied with the project. Therefore, it is suggested that the project institutions assign specific officer to handle the complaints and keep the complaint record and remedial measures. Level-by-level accountability system for dealing with the grievance should be implemented. The PMO of various levels should immediately make detailed record of the grievance after receiving it and records the complete treatment process, results and related data. In principle, the PMO should complete the treatment within 15 working days, inform the complainant of the results and disclose them in the relevant institutions and communities. The grievance handling staff should keep the grievant strictly confidential and is not allowed to inform the respondent of the information. 11.1.8 Vigorously publicize the World Bank-financed Projects The survey results show that only a very small portion of the aged, their family members and the aged-care service workers know this project, and people who are familiar with this project are even less. In order to make the World Bank-financed Project known to more people and allow them to actively participate in and supervise the project, it is suggested that: 1) In all the community aged-care service sites, nursing homes, social welfare homes and hospitals funded by the project, there should be a board to publicize the project. 2) On the uniforms of the staff of the government's purchased service, there should be the mark showing the support of World Bank loan. 3) Publicize the World Bank-financed Projects on various media. 4) Hold seminars and symposiums in the name of the World Bank-financed Project, 195 to promote a series of hot and cutting-edge topics, such as the socialization of aged-care services, and the combination of medical and health care. 11.1.9 Vigorously cultivate the ability of the social work organizations and volunteer organizations to provide community aged-care service 1) Encourage the social work organizations and volunteer organizations to closely cooperate with each other in the community and form the community service mode of social workers + volunteers. 2) Give economic and reputational incentives to the key organizer and activists in the interaction among the community, volunteers and social workers to improve their ability of aged-care service. 11.1.10 Give priority to women in terms of opportunities Although women account for the majority of aged-care service workers, they are inferior to men in terms of post, income and degree of education. Suggestions: 1) Give priority to women in terms of training and promotion opportunities; 2) Make sure that the women and men are equally paid when they do the same work. 196 Table 11-1 Social management plan Action suggestions Target group Specific measures or actions Actor Action time Monitoring index In the places where the demand for aged-care is Reasonably arrange the Project large, the sites may be constructed a little more, PMO, PIU and POU spatial location of the operation while in the places where the demand for in each city 2018- aged care sites unit (POU) aged-care is small, such as industrial area, commercial area, the sites might be less. Reduce the workload of Personnel of Hire experienced experts or expert team as Degree of satisfaction of government staff relevant soon as possible to effectively reduce the PMO 2018- government staff department workload of government staff. 1) Formulate the transition plan for the Reduce the negative implementation period of the project, eliminate 1) See the relevant impact of the project on the environmental impact and potential risks content of environmental aged-care service during construction, and reasonably arrange the impact assessment workers during its Employees work of staff and the transition of the aged; PIU 2018- 2) The implementation implementation 2) Develop talent motivation and training plan and the number of programs as soon as possible to address the trainers of the training need for human resources during the program implementation and operation of the project; 1) Formulate temporary transition plan for 1) See the relevant Reduce the negative the construction period to help the aged to content of environmental impact of the project on adapt to the new environment as soon as impact assessment; the aged during its The aged possible and to reduce the environmental PIU 2018- 2) Public price hearing implementation impact and potential risks during the 3) Formulate the construction; transition plan for the 2) Deliberate the change of service price. aged Residents in 1) Quantity and contents Reduce the impact on the 1) The original public activities in the PMO, the community, of the community other residents in community community should not affected; health departments, 2018- activities community and migrant 2) Prevent the communicable diseases maternal and child 2) Changes in cases of construction health departments communicable diseases workers in the project area See the external Reduce the resettlement Displaced Formulate the Resettlement Action Plan PMO 2018- monitoring of influence of the project person resettlement of displaced persons All the It is suggested that the project institutions Establish the grievance people in assign specific officer to handle the complaints PMO and PIU 2018- The complaint record mechanism project area and keep the complaint record and remedial and handling. measures. 197 1) In all the community-based aged-care service sites, nursing homes, social welfare homes and hospitals funded by the project, there should be a board to publicize the project. 2) On the uniforms of the staff of the government's purchasing healthcare service, Vigorous publicize the All the there should be the mark showing the support 1) Various publicity World Bank-financed people in of World Bank loan. PMO, PIU and POU 2018- materials Projects project area 3) Publicize the World Bank-financed 2) Seminars and Projects with various media. symposiums 4) Hold seminars and symposiums, in the name of the World Bank-financed Project, to promote a series of hot and cutting-edge topics, such as the socialization of aged-care services, and the combination of medical and health care. 1) Encourage the close cooperation between 1) The quantity of Vigorously cultivate the Community the social work organizations and volunteer communities where the ability of the social work aged-care organization in the community and form the service mode of social organizations and management community service mode of social workers + PMO, the community, workers + volunteers are volunteer organizations and service volunteers; volunteer and social 2018- implemented to provide community staffs, and 2) Offer incentives to the key organizers and work organizations 2) The quantity of aged-care service social work activists to improve their aged-care service volunteers who have organizations abilities obtained relevant qualifications 1) Give priority to women in terms of 1) Women’s salary Give priority to women Female training, promotion, and post; 2) The percentage of in terms of opportunities employees 2) Make sure that the women and men are POU, PMO 2018- female managers and equally paid when they do the same work. female technicians in all the female employees 198 11-2 Monitoring and evaluation Monitoring and evaluation is an important link to ensure that the project is implemented according to the project goals, and that the publicity of project information, public consultation and the social management plan designed in this report can be valued and implemented, and it is also an important error correction mechanism and participation mechanism of this project. Therefore, a monitoring and evaluation mechanism is established in this project, including internal supervision and external monitoring and evaluation. The internal supervision is conducted by the PMO by monitoring and evaluating the implementation progress of the project, the social management plan and the information disclosure and the public consultation plan, as well as the use of the project funds and the implementation of the rules and regulations. The external monitoring can be carried out by the PMO together with the external monitoring and assessment agency for resettlement action plan hired by it. The monitoring and evaluation institution should conduct regular tracking, monitoring and evaluation of the implementation of social management plan, give advisory opinions and submit the monitoring and evaluation report to the World Bank. 199 Appendix 1. Process of Social Survey No. Time Location Participants Major topics Remarks Lu An Municipal Civil Affairs Symposium on Afternoon Bureau, various Lu An Austin government's 1 of March 3, aged-care Hotel purchasing 2017 institutions, and services. social assessment group Lu An Municipal Civil Affairs Traditional Bureau, social Symposium on Morning of Chinese assessment group medical and 2 March 4, Hospital of Lu institutions, and aged-care 2017 An Traditional combination Chinese Hospital of Lu An Have a symposium Apartment to learn about the manager, nursing management and Yinhe Elderly workers, the aged, Afternoon operation of the Apartment in Civil Affairs 3 of March 4, apartment, and Jin’an District Bureau of the city 2017 carry out of Lu An City and district, and questionnaire social assessment survey among the group aged and staff Have a symposium Anfeng Managers (3), to learn about the Community nursing workers management and Aged-care (4), the aged (4), Afternoon operation of the Centerin Civil Affairs 4 of March 4, apartment, and Wangcheng Bureau of the city 2017 carry out Street, Jin’an and district, and questionnaire District of Lu social assessment survey among the An City group institution aged and staff Person in charge of the apartment, Have a symposium nursing workers to learn about the (5), the aged being This apartment management and cared for and the mainly Morning of operation of the Xinde Elderly family members provides 5 March 5, apartment, and Apartment (7), social services for the 2017 carry out assessment group aged in the questionnaire institution and countryside. survey among the Civil Affairs aged and staff Bureau of the city and district Have a symposium to learn about the Afternoon Lu An East Person in charge management and 6 of March 5, Giant of the company, operation of the 2017 Company staff and the aged company, and carry out questionnaire 200 survey among the aged and staff Have a symposium Both this center Person in charge to learn about the and Xinde of the center, staff, Home-based management and Elderly the aged, social Afternoon Aged-care operation of the Apartment assessment group 7 of March 5, Center in apartment, and belong to same institution, and 2017 Yu’an District carry out company and Civil Affairs of Lu An City questionnaire mainly serve Bureau of the city survey among the the aged in the and district aged and staff city. Have a symposium to learn about the TaoYuan management and Elderly Afternoon Person in charge operation of the This center is a Service Center 8 of March 5, of the center, staff apartment, and private in Pingqiao 2017 and the aged carry out enterprise. Town of Lu questionnaire An City survey among the aged and staff To learn about the bureau’s work and Interview of ideas about Morning of PMO of Lu Director Pan of the aged-care and 9 March 6, An Municipal Bureau, and social suggestions for 2017 Civil Affairs assessment group World Bureau Bank-financed Projects through the interview Have a symposium Development Person in charge to learn about the Service Center of the center, the management and of Family This center is Morning of aged, Lu An operation of the Planning completely run 10 March 6, Municipal Civil apartment, and Households in by the 2017 Affairs Bureau, carry out Zhuizimiao community. and social questionnaire community of assessment group survey among the Lu An aged and staff Learn about the social workers’ Lu An Qiming Morning of opinions about Social Person in charge 11 March 6, community Workers of the organization 2017 home-based Organization aged-care through interviews Have a symposium to learn about the Director Huang basic situation and Suzhou and Division-head development of Afternoon Jinmanlou Tian of Suzhou aged-care 12 of March 8, HuiYuan Civil Affairs undertaking in 2017 International Bureau, and social Suzhou and the Hotel assessment group opinions on World Bank-financed Projects. Morning of Hongxin Person in charge Have a symposium 13 March 9, Aged-care of the center, the to learn about the 201 2017 Center in aged, Lu An management and Baiyangzhai Municipal Civil operation of the Street, Affairs Bureau, apartment, and Yongqiao and social carry out District of assessment group questionnaire Suzhou survey among the aged and staff Have a symposium Person in charge to learn about the Nursing Home of the center, the management and in Zhaotun aged, Lu An operation of the Town, 14 2017/3/9 Municipal Civil nursing home, and Dangshan Affairs Bureau, carry out County, and social questionnaire Suzhou City assessment group survey among the aged and staff Have a symposium Qibei Person in charge to learn about the Xincheng of the center, the management and Nursing Home aged, Lu An operation of the in Yongqiao 15 2017/3/9 Municipal Civil nursing home, and District, Affairs Bureau, carry out Suzhou City, and social questionnaire Anhui assessment group survey among the Province aged and staff Have a symposium Person in charge to learn about the Nursing Home of the center, the management and in Pingshan Morning of aged, Lu An operation of the Town, Si 16 March 10, Municipal Civil nursing home, and County, 2017 Affairs Bureau, carry out Suzhou City and social questionnaire assessment group survey among the aged and staff Have a symposium Person in charge to learn about the Aged-care of the center, the management and Afternoon Center in aged, Lu An operation of the 17 of March10, Huangkou Municipal Civil apartment, and 2017 Town, Xiao Affairs Bureau, carry out County and social questionnaire assessment group survey among the aged and staff Have a symposium Person in charge to learn about the Fengmiao of the center, the management and Morning of Nursing Home aged, Lu An operation of the 18 March 11, in Lingbi Municipal Civil nursing home, and 2017 County, Affairs Bureau, carry out Suzhou City and social questionnaire assessment group survey among the aged and staff Have a symposium Anqing Person in charge Morning of to learn about the Municipal of the Bureau, and 19 March 12, basic situation and Civil Affairs social assessment 2017 development of Bureau group aged-care in 202 Anqing and the opinions on and suggestions of World Bank-financed Projects Have a symposium Anqing Municipal to learn about the Civil Affairs management and Yirentang in Afternoon Bureau, social operation of Yingjiang 20 of March assessment group, Yirentang, and District, 12, 2017 person in charge carry out Anqing City of Yirentang and questionnaire the aged survey among the aged and staff Have a symposium Aged-care Person in charge to learn about the Center of of the center, the management and Afternoon LashuYuan aged, Lu An operation of the 21 of March Community in Municipal Civil apartment, and 12, 2017 Daguan Affairs Bureau, carry out District, and social questionnaire Anqing City assessment group survey among the aged and staff Have a symposium Person in charge to learn about the Warm House of the site, the management and Home-based Afternoon aged, Anqing operation of the Aged-care Site 22 of March Municipal Civil apartment, and in Yangqiao 12, 2017 Affairs Bureau, carry out Town, Anqing and social questionnaire City assessment group survey among the aged and staff Learn about the Person in charge operation and of FushouYuan, Afternoon management of FushouYuan Anqing Municipal 23 of March FushouYuan in Anqing Civil Affairs 12, 2017 through Bureau, and social interviews, and assessment group visit it Have a symposium to learn about the basic situation and Department Wuhu Municipal development of meeting of Civil Affairs aged-care in Wuhu Morning of Wuhu Bureau, Wuhu 24 and the bureau’s March 14 Municipal Haoyan Company, opinions on and Civil Affairs and social suggestions of Bureau assessment group World Bank-financed Projects Have a symposium Wuhu Haoyan to learn about how Wuhu Haoyan Afternoon Company and the company 25 Company of March 14 social assessment carries out World group Bank-financed Projects 203 Have a symposium Aged-care to learn about the centers in management and Persons in charge Dafu operation of the Morning of of the centers, the 26 community apartment, and March 15 aged, and social and TingYuan carry out assessment group community of questionnaire Wuhu survey among the aged and staff Have a symposium Manager of the to learn about the Urban Welfare welfare home, the management and Home in aged and their operation of the Morning of Xuanzhou 27 family members, welfare home, and March 16 District, nursing workers, carry out Xuancheng and social questionnaire City assessment group survey among the aged and staff Have a symposium Manager of the to learn about the welfare home, the management and Ningguo aged and their operation of the Morning of 28 Social Welfare family members, welfare home, and March 17 Home nursing workers, carry out and social questionnaire assessment group survey among the aged and staff Have a symposium Management to learn about the personnel of the new progress of Department of the integrated Integrated Medical medical and and Aged-care aged-care service Project of project, and the Traditional Traditional opinions of the Morning of Chinese 29 Chinese Hospital staff, elderly June 29 Hospital of Lu of Lu An and patients and their An nurses in the family members Hospital, elderly on the project; and patients and their carry out family members, questionnaire social assessment among the aged group and their family members Social assessment group, management personnel of the Carry out Traditional Department of questionnaire Afternoon Chinese 30 Integrated Medical among the aged of June 29 Hospital of Lu and Aged-care patients and their An Project of family members Traditional Chinese Hospital of Lu An Morning of Renmin Social assessment Have a symposium 31 June 30 Xincun group, civil affairs to learn about the 204 Community in bureau staff, understanding and Zhongshi Sub-District evaluation of the Sub-district, Office and staff on the World Jin’an District, community Bank-financed Lu An City administrators, the Project and the aged and their integrated medical family members in and aged-care the community service project; and carry out questionnaire among the aged and their family members in the community Have a symposium to learn about the understanding and Social assessment evaluation of the group, civil affairs staff on the World Qing’an bureau staff, Bank-financed Community in Sub-District Project and the Afternoon Gulou Office and integrated medical 32 of June 30 Sub-district, community and aged-care Yu’an District, administrators, the service project; Lu An City aged and their and carry out family members in questionnaire the community among the aged and their family members in the community Have a symposium Social assessment to learn about the Suzhou group, Department details of the Morning of HuiYuan of Civil Affairs of 33 component 1 of July 1 International Anhui Province Department of Hotel Section chief Xu Civil Affairs of Min Anhui Province Have a symposium to learn about the understanding and evaluation of the Social assessment staff and the aged Zhenbei group, civil affairs on the World Village bureau staff, Bank-financed Afternoon Committee, Zhenbei Village Project and the 34 of Beiyangzhai, head, the aged in nursing home July 1 Suzhou Zhenbei Village upgrading & District, not living in reconstruction Suzhou City nursing home project; and carry out questionnaire among the aged and their family members Suzhou Social assessment Have a symposium Evening of HuiYuan group, Department to learn about the 35 July 1 International of Civil Affairs of understanding and Hotel Anhui Province evaluation of the 205 Section chief Xu aged-care Min, bosses and institutions bosses managers of and managers on aged-care the World Bank institutions component 1 Have a symposium to learn about the Social assessment understanding and group, civil affairs evaluation of the Houzhu department staff, staff and the aged Village Fengmiao nursing on the World Morning of Committee, home manager, Bank-financed 36 July 2 Fengmiao village secretary, Project and the Town, Suzhou the aged not living nursing home City in nursing home upgrading & and their family reconstruction members project; and carry out questionnaire among the aged Social assessment group, civil affairs Gaozhai department staff, Village, village secretary, Carry out Morning of 37 Fengmiao village branch questionnaire July 2 Town, Suzhou committee among the aged City member, the aged not living in nursing home Have a symposium to learn about the Social assessment understanding and group, civil affairs evaluation of the department staff, staff and the aged Aged-care Qiumiao Village on the World Afternoon Center in and Hongguang Bank-financed 38 of Yangtuan Village branch Project and the July 2 Town, Suzhou committee nursing home City members, the aged upgrading & not living in reconstruction nursing home project; and carry out questionnaire among the aged 206 Photo 1 Nursing home of Zhaozhuang Photo 2 Nursing Home in Zhaozhuang Town, Town in Dangshan County, Suzhou City Dangshan County, Suzhou City (dangerous (toilet) building) Photo 3 Public consultation (Suzhou: talking with staff from civil affairs 207 department and nursing home) Photo 4 Public consultation (Suzhou: talking with the aged in nursing home) Photo 5 Public consultation (Traditional Chinese Hospital of Lu An: talking with staff of the hospital, the old patients and their family members) 208 Photo 6 Public consultation (Suzhou: talking with the administrators of aged-care institutions) Photo 7 Questionnaire survey (Traditional Chinese Hospital of Lu An: the investigator and the old patient after the interview) 209