Abstract

Background: The reforms of care for older people have been embarked upon in China as a result of the dramatic demographic and social-economic changes since the 1980s. The market plays an increasingly active role in the field of care in urban China. Home care accords with the family-centred sociocultural norms and matches preferences of the state and older people and their families. In this context, policies in terms of developing the home care market are evidently employed in China.

Objectives: This study aims to examine how the marketization process is shaping home care policy and practice for older people in urban China. This paper investigates key strategies of the marketization of care being applied in Shanghai and impacts of the marketization on participants in the care market and the entire care regime.

Methods: A qualitative case study approach was adopted for the empirical research in Shanghai. The data source consists of i) 30 semi-structured interviews with 9 local government officials and 21 care provider representatives in 2016 and ii) 4 follow up interviews with 2 government officials and 2 care managers in 2018. Thematic analysis was applied to analyse the interview data.

Results: Providing an in-depth exploration of the marketization of care in the Chinese context, this paper examines pathways of the marketization, dynamics of stakeholders in the mixed economy of care, and outcomes and risks of the marketization. Three quasi-market models (i.e. the state-controlled model, the limited competition model, and the free market model) have been identified based on different state-market relations and competition levels between care providers. Each model is shaped by different contracting out strategies, financial support methods, hierarchies of power in the care market, and how it influences the state-market relations in turn. As the marketization of care for older people is developing at a rapid path in Shanghai, different outcomes come along the process, including crude efficiency (allocating more attention to the increase of the care supply than care quality), unequal competition between care providers due to the preferences and interference of local governments in the commissioning, operations and monitoring, and disputes around for-profit motivations of providers.

Conclusions: Care for older people in urban China is changing from the monopolistic state-based provision to a quasi-market, in which social service agencies compete for public contracts, consumers purchase care services with vouchers and subsidies, and agents represent consumers in the care market. The application of market mechanisms leads to changes in the shapes and implications of the provision and financing dimensions of care for older people. This study not only contributes to the understanding of the marketization of care in China but also the theoretical discussions of long-term care markets in the international context.

Slides