While the money might be coming in and the regulations may be favorable, foreign investors face daunting cultural barriers.

For hundreds of years, Chinese familial tradition has put it upon children to take care of their elderly parents.

The notion of filial piety has carried on in modern times: In 1996 the government set out a policy that required children to take care of their aged parents.

But as more and more families opt to live in dual-income households and as the pressures put on families by the family planning policy increase, many children are now left to take care of both their parents as well as four grandparents - a concept known as the "421" family structure in China.

"The situation is more serious due to the '421' family structure. It generates more empty-nest families who will need institutional care," Qu says.

He says the real crunch will come after 2015, making now the optimal time for foreign businesses to enter the market.

"The timing at present is ripe for foreign investors to enter the market and build their brand."

Already, families are recognizing the pressure put on children and the need to adapt to China's transforming family structure.

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"With the rapid growth of China, many have changed their train of thought. People are starting to live individually, paying for their own care individually," says Ma Zhang, 83, a retired government official who has been using US-based Right-At-Home Care, an in-home nursing service, for more than a year.

Speaking in a lavishly decorated two-story apartment in Beijing's Fengtai district where he lives with his 81-year-old wife, Xie, the energetic octogenarian says they began using the service to help alleviate the pressure on their two children.

With their daughter working as an auditor in the US and their son working for a large telecommunication firm in the capital, he says it is difficult for their children to find time to visit.

"My children are very busy, so it gets quite lonely every day," Ma says.

The caretaker not only monitors their health and helps with housework, but they converse with the elderly couple throughout the week. That seemingly mundane but necessary task was one of the driving factors for Ma and his wife.

At 20,400 yuan a month, paying for conversation may seem extravagant, but paying for foreign senior care is also a sign of status, akin to owning a nice car.

"We chose this brand because it is American and we knew it would be high quality. Many of our friends admire our ability to afford this kind of service."

This positive perception of foreign brands is giving companies like Right-At-Home and Cascade a leg up when angling for middle-class families who can afford to pay for quality senior care.

Another cultural barrier for foreign companies breaking into the market is the perception that senior assisted living can be a sign of luxury. In many cities across China, many of the current senior health facilities are funded by government and geared toward low-income families.

"In the past 10 to 20 years almost all of the senior facilities were created by the government and geared toward low income. Because of this (assisted living) has a very bad reputation," Xie of Cascade Healthcare says.

She says if senior care companies want to see the industry grow, they must convince the younger generation that putting their parents in assisted living is not necessarily a bad thing.

"I think for us, making money is one thing, but more important it's that we want to make a difference here. We want to show people what it's like for seniors in developed countries to live," Xie says.

In addition to tackling perception, there is also the reality of numbers.

Ninety percent of seniors will either remain "aging-in-place", or living on their own or with their children, while 7 percent will live in community or government housing geared for those on a low income. Three percent are in high-end private housing centers.

This means high-end foreign healthcare providers are targeting just 5.4 million of China's 181 million elderly population, indicating that the market may not be as large as companies hope.

But the number of the nation's retirees is skyrocketing, meaning the number of seniors looking for high quality may also grow.

Though the need to deal with the rapidly aging population is an immediate and real concern, investment in China has changed and businesses must be cautious before leaping into unknown markets, says Shobert of Rubicon Strategy Group.

"Now, foreign operators are very focused on a patient and disciplined approach that emphasizes market research, cautious build-outs, and careful selection of which demographic or market niche to emphasize."

Whether or not foreign investors have waited long enough to re-invest efforts into getting a foothold in China is still unknown. For now, many are still adopting a wait-and-see attitude.

"The question of whether the industry has the elasticity to absorb excess capacity, learn from early mistakes, and then re-deploy across China in a time frame to make for a compelling industry opportunity or to address the very real human needs this industry serves, remains to be seen," Shobert says.

toddbalazovic@chinadaily.com.cn

(China Daily 11/30/2012 page12)