Legal Regulation of Sustainable Delivery of Government-Procured Public Elderly Care Services in China’s Moderately Aging Society: Dilemmas and Legalization Pathways

Abstract

As China rapidly transitions to a moderately aging society, the sustainable delivery of public elderly care services has emerged as a critical legal and governance challenge. Government procurement has become a pivotal mechanism through which the state engages both social and market actors in providing elderly care services. However, the sustainability of this service delivery mechanism remains constrained by fragmented legal norms, unstable fiscal guarantees, inconsistent service standards, weak supervision, and regional inequalities. This article examines how legal regulation can support the sustainable delivery of government-procured public elderly care services in China. Based on qualitative, desk-based legal and policy analysis, it reviews the evolution of China’s national and local regulatory framework, assesses the current system from the perspectives of institutional, fiscal, social, and governance sustainability, and identifies key legal and institutional dilemmas, arguing that China should construct a hierarchical legal framework, establish stable fiscal guarantee rules, develop unified service standards, strengthen whole-process supervision, and improve legal mechanisms for regional coordination. These reforms would enhance the rule-of-law foundation of government-procured elderly care services and provide a reference for other aging societies seeking sustainable public service delivery models.

1. Introduction

The global wave of population aging has become a core challenge affecting the sustainable development of countries around the world, and it is highly relevant for the United Nations Sustainable Development Goals (SDGs), especially SDG 3 (Good Health and Well-being), SDG 10 (Reduced Inequalities), and SDG 11 (Sustainable Cities and Communities). As the country with the largest elderly population in the world, China has become a moderately aging society: by the end of 2025, the population aged 60 and above reached 323 million, accounting for 23.0% of the total population, and the population aged 65 and above reached 224 million, accounting for 15.9% of the total population. The shrinking working-age population (with an average annual decrease of about 5 million people aged 15–64) and the collapse of the traditional family care model have made the sustainable supply of elderly care services a core issue related to long-term social stability and intergenerational equity.

Against this background, the government procurement of public elderly care services has become a core institutional innovation to address the aging challenge in China (Ren and Li 2024), transforming the government from a direct producer of public services to an arranger and supervisor, and it has built a multi-stakeholder collaborative supply model of “government leadership, social participation, and market operation”. As Liu (2018) argues, the government procurement of services emphasizes contract spirit, performance orientation, equal participation, and transparency, which are inherently consistent with the concept of modern national governance and have positive significance for promoting the transformation of China’s national governance modernization. However, the current practice of the government procurement of public elderly care services in China is facing multiple sustainable development constraints: the fragmented legal system leads to unstable institutional expectations, the unsustainable financial guarantee mechanism limits the coverage of services, the service supply–demand mismatch damages social equity, and the imperfect regulatory system leads to frequent quality risks (Li 2017; Yang 2021; J. Zhang 2021; Yu 2017). Existing studies have confirmed that the government procurement of public elderly care services can significantly enhance the life satisfaction of functionally limited middle-aged and elderly individuals (Zhao and Liu 2026), but its institutional and legal dilemmas have become the core bottleneck restricting the sustainable development of the system.

Existing studies on the government procurement of elderly care services in China mostly focus on public administration and economic efficiency analysis, while few studies systematically explore the legalization path of this service model from the perspective of social sustainability (Y. Zhang 2024; Yan and Xu 2024). From the perspective of complex networks, Lu et al. (2022a) explore the anti-risk ability of the government purchase of elderly care services, finding that the lack of a sound legal and regulatory system significantly reduces the anti-risk ability of the policy system. Technical characteristics of intelligent elderly care services also have a significant impact on customer satisfaction and sustainable service development, which provides a new perspective for the sustainable delivery of public elderly care services through government procurement in the digital age. This study takes the national overall data as the core, combines the innovative practices of typical provinces such as Jiangsu and Zhejiang with intensive policy introduction, systematically sorts out the evolution of China’s policy and legal system for the government procurement of public elderly care services over the past 5 years, evaluates the sustainability of the current system through empirical data, analyzes the legal and institutional dilemmas restricting its sustainable development, and finally, puts forward a targeted legalization improvement path. This research provides a legal solution for building a sustainable elderly care service system for China’s moderately aging society as well as a reference for developing countries facing similar aging challenges.

This article addresses three research questions: (1) How has China’s legal and policy framework for the government procurement of public elderly care services evolved in recent years? (2) What legal and institutional dilemmas restrict the sustainable delivery of public elderly care services through government procurement? (3) What legalization pathways can improve the institutional, fiscal, social, and governance sustainability of this service delivery mechanism?

Methodologically, this study is a qualitative, desk-based legal and policy analysis combining doctrinal analysis of laws, administrative regulations, policy documents, and local rules with a structured review of the Chinese and international literature on public procurement, social service delivery, elderly care governance, and public service contracting. The analysis is organized around four sustainability dimensions: institutional sustainability, fiscal sustainability, social sustainability, and governance sustainability. These dimensions are used to connect the findings in Section 5 with the reform pathways proposed in Section 6.

In this article, “sustainable delivery of public elderly care services through government procurement” does not refer to the abstract sustainable development of procurement as an administrative technique but rather refers to the capacity of a government-procured service system to provide elderly care services over time in a legally stable, fiscally viable, socially equitable, and effectively supervised manner. This clarification is important because government procurement is treated here as one institutional instrument for public service delivery and not as an end in itself.

2. Theoretical Framework and Literature Review

2.1. Core Theoretical Foundation

This study constructs an analytical framework based on four complementary theoretical perspectives: social sustainability theory, institutional theory, principal–agent theory, and public goods theory. Together, these perspectives connect the legal analysis of government-procured public elderly care services with the broader question of sustainable public service delivery.

To strengthen the international dimension of the theoretical framework, this study situates China’s experience within broader debates on public service delivery, public service contracting, and social service governance. International studies show that contracting out, vouchers, subsidies, direct public provision, public–private partnerships, and co-production are all used to deliver social services; however, their suitability depends on the service characteristics, information asymmetry, measurability of quality, and vulnerability of service users (OECD 2011; OECD 2015; Bovaird 2007; Le Grand 2007). In elderly care, these factors are especially important because service quality is relational, difficult to observe fully, and closely connected with dignity, safety, and social rights. Among these, direct public provision remains the backbone of elderly care in many developed welfare states while contracting and vouchers tend to be applied to supplementary or non-core services.

Social Sustainability Theory: The core connotation of social sustainability in the elderly care field includes three dimensions: equity (ensuring equal access to basic elderly care services for all elderly groups), accessibility (matching the supply of services with the actual needs of the elderly), and intergenerational solidarity (building a long-term sustainable care system to balance the interests of different age groups). The government procurement of public elderly care services, as a core institutional arrangement to realize the social rights of the elderly, directly determines the sustainability of the elderly care service system (Fang and Fu 2021). The spatial non-equilibrium of China’s elderly care policy has further highlighted the importance of equity and accessibility in the social sustainability of elderly care services.

Institutional Theory: Institutional theory provides an important analytical lens for understanding why the sustainability of government-procured public elderly care services depends not only on policy objectives or financial inputs, but also on the stability, coherence, and enforceability of the institutional rules that structure public service delivery. Recent public administration scholarship has reaffirmed the relevance of institutional theory for explaining how formal and informal institutions, legal rules, policy arrangements, and state structures shape governance processes and public management outcomes (Silva et al. 2024; Singh 2024). In this article, institutions mainly refer to formal legal and policy arrangements that define the responsibilities of public authorities, the obligations of service providers, the rights of older persons, and the procedures for financing, standard-setting, supervision, and accountability. From this perspective, fragmented norms, unclear hierarchical relationships among legal sources, weak implementation rules, and unstable fiscal or supervisory arrangements may undermine institutional sustainability even when service demand and policy support are strong. Institutional theory therefore helps explain why the legalization of government-procured elderly care services is central to sustainable delivery: legal norms do not merely authorize procurement activities, but also stabilize expectations, allocate responsibilities, constrain administrative discretion, and provide mechanisms for accountability and rights protection. This perspective is also consistent with recent studies on public service delivery and collaborative governance, which show that institutional capacity, accountability arrangements, external supervision, civil society engagement, and public participation are important for improving service delivery and reducing governance risks (Zia ud din et al. 2023; Zarychta et al. 2024). It directly supports the article’s focus on institutional sustainability, fiscal responsibility, service standards, whole-process supervision, and regional coordination.

Principal–Agent Theory: The government procurement of public elderly care services essentially forms a double principal–agent relationship: the public entrusts the government with the supply right of public elderly care services through tax payment, and the government entrusts the specific production of services to social organizations and market entities through purchasing contracts. The information asymmetry in this relationship is the core source of risks such as adverse selection and moral hazard, and a sound legal system is the core mechanism to standardize the rights and obligations of all parties and control agency risks (Jensen and Meckling 1976; Lin 2015; Jiang et al. 2023; Jiang and Chen 2017). Existing studies have explored the anti-risk ability of this service-purchasing model from the perspective of complex networks (Lu et al. 2022a) and have confirmed that the lack of a sound legal and regulatory system significantly reduces the anti-risk ability of the policy system.

Public Goods Theory: Public elderly care services are quasi-public goods, with both non-competitive and non-exclusive characteristics of public goods and private attributes provided by the market. According to this attribute, the government must assume the core responsibility of system supply, financial guarantee, and supervision, and the legal system is the core basis for clarifying the boundary of government responsibility and standardizing the participation of market entities. In the practice of the government procurement of public elderly care services, the government’s role has shifted from that of a direct service provider to that of a supervisor responsible for ensuring service quality provided by social entities, which is the core embodiment of the government’s public goods supply responsibility (J. Zhang 2021). Zhang et al. (2016) emphasize that the government should pursue not only the efficiency but also the quality of public services when purchasing, avoiding power rent seeking.

These theoretical perspectives and related studies provide the conceptual background for understanding public service delivery instruments, while recent empirical and policy studies on long-term care financing, elderly care procurement, and quality regulation further specify how these instruments operate in aging societies (Song et al. 2020; OECD 2023; World Health Organization 2024; Pot et al. 2024).

2.2. Literature Review

The recent international literature from the last decade has increasingly examined elderly care and long-term care service delivery through the lenses of fiscal sustainability, service quality regulation, user choice, contracting accountability, and social equity. This body of research shows that aging societies face not only the quantitative challenge of an expanding elderly care supply but also the institutional challenge of designing legally stable, fiscally viable, and accountable service delivery mechanisms. International organizations have also emphasized that long-term care financing usually relies on a combination of general taxation, social insurance, out-of-pocket payments, and private or community contributions, and that the institutional design of financing mechanisms affects equity, financial protection, and service sustainability (OECD 2023; World Health Organization 2024). These studies are directly relevant to the fiscal sustainability dimension of government-procured elderly care services because a procurement-based service model cannot remain sustainable if the funding rules are unstable, fragmented, or excessively dependent on short-term, local fiscal discretion.

A second strand of the recent literature focuses on the quality risks created by contracting and procurement in elderly care. Song et al. (2020) examine the government procurement of elderly care services from market-oriented private providers and argue, from a principal–agent perspective, that asymmetric information and goal divergence between governments and providers may increase quality risks. Their study emphasizes the importance of ex ante policy design in reducing these risks before service contracts are implemented. This finding is highly relevant to the present article because public elderly care services involve vulnerable beneficiaries, non-contractible quality dimensions, and limited user capacity to monitor providers, supporting the argument that the government procurement of elderly care services should not be treated as ordinary goods procurement but as a welfare-oriented service delivery mechanism requiring stricter provider qualification rules, service standards, monitoring procedures, and legal accountability.

A third strand of the recent international research concerns the regulation and quality assurance of long-term care. Pot et al. (2024), in a scoping review of empirical studies on long-term care regulation for older persons, show that regulation is not limited to the responsibility of care professionals but also involves regulators and other stakeholders. Their review highlights the need to understand how regulatory practices are put into operation in order to guarantee or improve quality of care. This literature is important for the governance sustainability dimension of this article. In government-procured elderly care services, quality cannot be secured merely through contract signing or price-based procurement. Instead, service standards, inspection, complaint mechanisms, information disclosure, and whole-process supervision must be legally institutionalized.

A fourth strand of the literature examines vouchers, consumption subsidies, and other demand-side instruments in elderly and primary care. Studies on Hong Kong’s Elderly Health Care Voucher Scheme show that vouchers can encourage older persons to use private services but do not necessarily reduce reliance on public services or ensure continuity of care (Yeoh et al. 2020; Chong et al. 2021; Fung et al. 2022). Research on Hong Kong’s Community Care Service Voucher Scheme further suggests that voucher-based mechanisms may enhance user autonomy and provider participation, but their effectiveness depends on utilization, affordability, service matching, and administrative design (Lam 2023). These studies are important for the Chinese context because recent elderly care service consumption subsidies similarly aim to shift from government-assigned services to greater user choice. However, the international literature warns that vouchers and subsidies are not substitutes for legal rules on eligibility, provider accreditation, service catalogs, price regulation, quality monitoring, or grievance mechanisms.

Recent public contracting scholarship also provides useful insights for this article. FitzGerald and Macdonald (2024) show that governments increasingly rely on contracts and cross-sectoral networks to deliver public services; however, outcome-based contracting may also allow governments to avoid active contract management or sidestep public law accountability if responsibilities are not clearly defined. This insight is particularly relevant to elderly care services, where the state remains responsible for protecting vulnerable older persons even when service delivery is delegated to social organizations or market actors. Therefore, procurement, contracting, vouchers, and subsidies should be understood as operational tools within a broader public service delivery framework rather than as substitutes for public responsibility.

In the domestic research, Chinese scholars have carried out in-depth discussions on the policy practice, operational model, and existing problems of the government procurement of public elderly care services. Existing studies have confirmed that this service-purchasing model has improved the supply efficiency of elderly care services in China but still faces multiple dilemmas, such as an imperfect legal system, unstable fiscal mechanisms, uneven service standards, and inadequate supervision (Chu and He 2018; Yu 2017; Zou 2017; Wang and Wang 2021; Yan and Xu 2024). From the perspective of complex networks, scholars have analyzed the vulnerability and quality control issues of this purchasing model and pointed out that the imperfection of the legal and regulatory system is an important source of policy system vulnerability (Zhang et al. 2022; Lu et al. 2022b), and local elderly care legislation has also been found to affect the transformation of elderly care methods by consolidating family care and improving the level of social care. However, most of the existing domestic studies focus on policy effects, operational models, or public administration efficiency, while relatively few studies systematically explore the legalization pathway of the government procurement of public elderly care services from the integrated perspective of institutional, fiscal, social, and governance sustainability.

Taken together, the recent international literature provides three implications for the present study. First, elderly care procurement requires stable financing rules and cannot rely solely on short-term administrative projects. Second, because elderly care quality is relational, continuous, and difficult to measure, legal rules must address provider access, service standards, process supervision, and beneficiary protection. Third, demand-side instruments such as vouchers and subsidies may improve user choice but must be embedded in a legal framework that protects equality, accountability, and public responsibility. Building on these insights, this article examines how China can strengthen the legal regulation of government-procured public elderly care services to support sustainable service delivery in a moderately aging society.

3. Evolution of China’s Policy and Legal System for Government Procurement of Public Elderly Care Services in Recent 5 Years

3.1. Institutional Context of Government Procurement and Purchase of Services in China

In Chinese legal and policy discourse, “government procurement” generally refers to the use of fiscal funds by state organs, public institutions, and organizations to procure goods, construction works, and services through statutory procedures. By contrast, “government purchase of services” is a service delivery mechanism through which the government uses public funds to commission qualified social organizations, enterprises, or public institutions to provide public services to eligible groups. The public elderly care services discussed in this article belong mainly to the latter category, although they are also affected by the broader government procurement framework.

This distinction also clarifies the relationship between procurement, vouchers, and service delivery in this article. Procurement or purchase of services refers to the institutional arrangement by which the government selects, funds, and supervises service providers. Vouchers and consumption subsidies are not separate research objects; they are payment or demand-side instruments within the broader service delivery system. Therefore, this article focuses on the legal regulation of government-procured elderly care service delivery while recognizing that local governments may use different operational tools, including contracts, service lists, points, vouchers, and subsidies.

In this institutional setting, government-procured elderly care services should be understood as a hybrid mechanism combining fiscal expenditure, welfare service delivery, and contractual governance. Unlike the ordinary procurement of goods or construction works, elderly care service procurement involves continuous interpersonal services, vulnerable beneficiaries, and quality dimensions that are difficult to specify completely in advance. The quality of daily care, emotional support, dignity protection, safety management, and responsiveness to changing care needs cannot be fully reduced to price-based bidding criteria. Therefore, the legal regulation of this field must go beyond procedural compliance in procurement and address substantive questions of service standards, provider qualifications, beneficiary rights, complaint channels, and long-term supervision. This view is consistent with recent public contracting scholarship, which stresses that public service contracts should not be treated merely as transactional instruments but as governance mechanisms for achieving social outcomes and maintaining public accountability (FitzGerald and Macdonald 2024).

This feature also explains why contracts, service lists, points, vouchers, and subsidies should not be treated as separate systems, as they are different operational instruments within the same public service delivery framework. Contract-based procurement mainly concerns the selection, payment, and supervision of service providers, while vouchers and consumption subsidies strengthen user choice by allowing older persons to select qualified services within a publicly defined scope. However, demand-side instruments still require public regulation. Without legally defined service catalogs, eligibility criteria, price standards, provider accreditation, and performance evaluation, vouchers may increase formal choice without ensuring equal access or stable quality.

The Chinese system is therefore characterized by a combination of supply-side contracting and demand-side subsidy instruments. This combination may improve flexibility and responsiveness but also creates regulatory challenges. The government must simultaneously act as purchaser, funder, standard-setter, market regulator, and rights protector. The central legal issue is not whether the government should use procurement or subsidies but how the law can define the responsibilities of public authorities, the obligations of service providers, and the rights of older persons within a sustainable service delivery system.

For this reason, the following analysis treats government-procured public elderly care services as a legally structured welfare service mechanism rather than a narrow procurement technique, the sustainability of which depends on whether the legal system can provide stable rules for institutional hierarchy, fiscal responsibility, service standards, whole-process supervision, and regional coordination.

3.2. Construction of Top-Level Legal and Policy Framework

In the past 5 years, China has basically completed the construction of the “four beams and eight pillars” of the legal and policy system for the government procurement of public elderly care services, forming a hierarchical framework with the Law on the Protection of the Rights and Interests of the Elderly as the core, central policy documents as the support, and local regulations and rules as the implementation basis (Wang and Wang 2021).

At the legal level, the Law on the Protection of the Rights and Interests of the Elderly (revised and amended four times) has established the basic legal basis for the government procurement of public elderly care services. Article 31 of the law clearly stipulates that people’s governments at all levels should develop urban and rural community elderly care services through purchasing services, and Article 37 stipulates that governments and relevant departments can support social capital in establishing elderly care service institutions through measures such as purchasing services, providing the fundamental legal basis for the implementation of this service procurement mechanism. However, existing provisions in upper-level laws are still overly principled and lack operable implementation rules, resulting in significant differences in policy norms across regions and a fragmented implementation system in practice (Yu 2017; J. Zhang 2021).

At the central policy level, the past 5 years have seen a major breakthrough in the top-level design of the government procurement of public elderly care services. As early as 2014, the Ministry of Civil Affairs and the Ministry of Finance issued a special notice to comprehensively deploy the government’s purchase of elderly care services, laying an early policy foundation for the development of this purchasing system. In 2020, the Ministry of Finance issued the Measures for the Administration of Government Purchase of Services, which further standardized the scope, procedures, and supervision of the government purchase of services, and provided a unified regulatory basis for the government procurement of public elderly care services. In December 2020, the General Office of the State Council issued the Opinions on Establishing and Improving the Comprehensive Supervision System for Elderly Care Services, which clarified the full-process supervision framework for the government procurement of elderly care services. In 2022, the General Office of the Central Committee of the Communist Party of China and the General Office of the State Council issued the Opinions on Promoting the Construction of the Basic Elderly Care Service System, which, for the first time, clearly defined the connotation of basic elderly care services and clarified that the government procurement of public elderly care services is the core mechanism for the government to assume the responsibility of basic elderly care services, emphasizing the principles of universality, equity, and sustainability of services. This policy has further clarified the core position of the government procurement of services in the basic elderly care service system and also provides a top-level policy basis for list-based management and standardization construction at the local level (Yu 2017). In 2025, the Ministry of Civil Affairs and the Ministry of Finance jointly issued the Notice on Implementing the Project of Distributing Elderly Care Service Consumption Subsidies to Moderately and Severely Disabled Elderly, implementing the elderly care service consumption subsidy system nationwide from 1 January 2026, and realizing the transformation of this service-purchasing model from “government assigned orders” to “elderly selected orders”, which is a major innovation in the sustainable operation mechanism of the government procurement of public elderly care services. The core policy and legal norms from 2020 to 2025 have formed a progressive institutional system, and the key content and institutional value of each core document are presented in

Table 1. Evolution of core policies and legal norms for government procurement of public elderly care services in China (2020–2025).

Year	Policy/Legal Document	Key Content	Institutional Value
2020	Measures for the Administration of Government Purchase of Services (Ministry of Finance)	Standardized the scope, procedures, and supervision of the government purchase of services	Provides a unified regulatory basis for the government procurement of elderly care services
2020	Opinions on Establishing and Improving the Comprehensive Supervision System for Elderly Care Services (General Office of the State Council)	Clarified the full-process supervision framework for the government procurement of elderly care services	Establishes a foundation for multi-departmental, collaborative supervision
2022	Opinions on Promoting the Construction of the Basic Elderly Care Service System (General Office of the CPC Central Committee and General Office of the State Council)	Defined basic elderly care services; clarified government procurement as the core way to assume responsibility; emphasized universality, equity, and sustainability	Provides a top-level policy basis for list-based management and standardization at local levels
2025	Notice on Implementing the Project of Distributing Elderly Care Service Consumption Subsidies to Moderately and Severely Disabled Elderly (Ministry of Civil Affairs and Ministry of Finance)	Implemented the consumption subsidy system nationwide from 1 January 2026; transformed the model from “government assigned orders” to “elderly selected orders”	A major innovation in the sustainable operation mechanism

.

3.3. Local Innovative Practice and Legal System Construction

In the past 5 years, local governments have implemented a large number of innovative practices in the government procurement of public elderly care services and formulated corresponding local regulations and rules, forming a number of typical models with sustainable development potential. By the end of 2024, 21 provinces in China had issued provincial-level local legislation on elderly care services, and 58 prefecture-level cities had formulated corresponding municipal regulations, which have become an important part of the legal system for the government procurement of public elderly care services.

Jiangsu Province, as a province with a high degree of aging and intensive policy innovation, has taken the lead in completing the local legal system construction of the government procurement of public elderly care services (Ren and Li 2024). The practice in Jiangsu has also confirmed that local elderly care service legislation has a significant positive effect on the transformation of elderly care service models, effectively consolidating the practical results of the government procurement of services and providing a replicable sample for the improvement of the national system (Wang and Wang 2021; Zou 2017). Relevant studies have summarized the sustainable community-based elderly care service models formed in Jiangsu Province through long-term policy practice, providing a replicable sample for the national promotion of government procurement systems. The province has issued the Implementation Opinions on Promoting the Development of Elderly Care Undertakings and Industries and Improving the Quality of Elderly Care Services, which clearly stipulates the scope, subject, procedure, and supervision mechanism of the government procurement of public elderly care services and requires the government to increase the purchase of services such as elderly ability assessment, home-based elderly care services, and elderly care worker training. Among them, the reform practice of Jiangyin City is particularly typical: the city has changed the original model of government-designated service providers to independent choice by the elderly, expanded the number of service providers from 5 to 28, converted the original government subsidies to service providers into equivalent points issued to the exclusive accounts of the elderly on a monthly basis, and expanded the service items from 28 items in four categories to 63 items in seven categories, which has significantly improved the matching degree between the service supply and demand and the sustainability of the system.

Zhejiang Province has formed a characteristic practice in the legalization of the elderly care service subsidy system. The province has formulated the Measures for the Administration of Elderly Care Service Subsidies in Zhejiang Province, which clearly defines the subsidy objects, standards, fund sources, and use supervision of the government procurement of public elderly care services and stipulates that elderly care service subsidies can be used to purchase home-based community or institutional elderly care services. These measures realize the full coverage of the subsidy system for low-income disabled and elderly people, which has laid a legal foundation for the equitable and sustainable supply of services. The resource allocation approach based on quality function deployment adopted in the practice of Zhejiang Province has also realized the optimal allocation of limited resources under the goal of maximizing public satisfaction (Xu and Zhang 2021), which provides a practical reference for the optimization of the government procurement of public elderly care services. Moreover, Zhejiang Province’s standardized subsidy management mechanism has realized the precise allocation of financial funds, effectively mobilizing social resources to participate in the supply of elderly care services (Jiang and Chen 2017).

4. Current Situation and Sustainability Assessment of China’s Government Procurement of Public Elderly Care Services

4.1. Overall Scale and Financial Input of Government Procurement of Public Elderly Care Services

In the past 5 years, the scale of China’s government procurement of public elderly care services has expanded rapidly, and the financial input has maintained a sustained growth trend, laying a financial foundation for the sustainable development of the system. From 2019 to 2024, the financial expenditure of governments at all levels on elderly care services (excluding infrastructure investment) and elderly welfare reached 567.6 billion yuan, with an average annual growth rate of 8.43%, which is higher than the average annual growth rate of the national fiscal expenditure in the same period. In 2024 alone, the national expenditure on elderly welfare funds reached 48.94 billion yuan, and the expenditure on elderly care service funds reached 25.32 billion yuan, most of which were used for the government procurement of public elderly care services.

In terms of central financial support, from 2019 to 2024, the central government allocated more than 150 billion yuan through general public and government fund budgets to support local governments in carrying out the government procurement of public elderly care services. In 2025, the central government allocated 1.16 billion yuan of the first batch of elderly care service consumption subsidy funds to support seven pilot regions to implement the study project, including Zhejiang, Shandong, and Chongqing. As of 8 October 2025, the pilot regions had issued 365,100 consumption vouchers, with 243,200 uses and a verification amount of 182 million yuan, showing a good sustainable operation effect. Existing studies have found that fiscal subsidies can effectively improve the technical efficiency of elderly care institutions, and for every 10,000 yuan increase in fiscal subsidies, the comprehensive technical and pure technical efficiencies of elderly care institutions increase by 0.244 and 0.181, respectively (Zhang and Zhang 2024), which confirms the positive role of financial input in the government procurement of public elderly care services. Relevant studies have also confirmed that continuous financial investment and standardized fund management mechanisms can effectively mobilize social resources to participate in the supply of elderly care services, promote the rapid growth of social organizations, and form a positive interaction between the government, the market, and society (Jiang and Chen 2017).

4.2. Supply Structure and Service Coverage of Government Procurement of Public Elderly Care Services

At present, China’s government procurement of public elderly care services has basically formed a service supply system covering “institutional + community + home-based” elderly care, and the service coverage has been continuously expanded. By the end of 2024, there were 406,000 various elderly care institutions and facilities nationwide, with a total of 7.993 million elderly care beds, of which 40,000 registered elderly care institutions had 5.077 million beds. Moreover, the proportion of nursing beds reached 65.7%, an increase of 17.7 percentage points compared with that in 2020, which has basically met the nursing needs of disabled elderly people.

The government has realized the full coverage of community elderly care services in urban areas and in more than half of rural areas through purchasing services. The Ministry of Civil Affairs has selected 184 regions to carry out the home-based and community basic elderly care service improvement action project, supporting the construction of 347,000 family elderly care beds and providing 643,000 person-times of home-based elderly care door-to-door services. Since the 14th Five-Year Plan period, the project has supported the construction of 441,000 family elderly care beds and provided 798,000 person-times of home-based elderly care door-to-door services, which has effectively improved the accessibility of home-based elderly care services. However, there are still significant gaps in the resource efficiency of institutional elderly care between urban and rural areas in China, and the supply capacity of elderly care services in rural areas is still significantly weaker than that in urban areas.

4.3. Sustainability Assessment of Current Government Procurement System of Public Elderly Care Services

This study assesses the current system of government-procured public elderly care services in China based on four analytical dimensions: institutional sustainability, which refers to the stability, hierarchy, and operability of legal norms; fiscal sustainability, which refers to the adequacy, predictability, and diversification of funding; social sustainability, which refers to equity, accessibility, and responsiveness to the needs of older persons; and governance sustainability, which refers to supervision, accountability, information disclosure, and beneficiary participation. The overall assessment results, core evaluation indicators, and main constraints of each dimension are summarized in

Table 2. Sustainability assessment of China’s government-procured public elderly care service system.

Sustainability Dimension	Core Evaluation Indicators	Current Status	Main Constraints
Institutional Sustainability	Legalization level; hierarchical norm completeness	Policy framework formed, but legalization level low; core provisions scattered in policy documents	Upper-level law too principled; lack of special administrative regulations; fragmented local rules
Fiscal Sustainability	Fiscal input growth; diversified funding mechanisms	Sustained growth (8.43% annually, 2019–2024), but mainly relies on general public budget	No rigid fiscal input mechanism; insufficient legal norms for social capital participation; weak fund use performance evaluation
Social Sustainability	Equity; accessibility; intergenerational solidarity	Service coverage expanded; 7.993 million beds; urban coverage: full; rural: >50%	Regional imbalance (east vs. west); urban–rural gap; service content limited (mostly basic care); lack of demand assessment mechanism
Governance Sustainability	Supervision clarity; accountability; information disclosure; beneficiary participation	Multi-departmental supervision framework exists, but whole-process quality supervision remains weak	Overlapping responsibilities; insufficient service quality monitoring; weak social supervision and complaint mechanisms

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Institutional Sustainability: The current system has basically formed a policy framework, but the legalization level is low. The core provisions of this service-purchasing model are mostly concentrated in policy documents, and the provisions in the Law on the Protection of the Rights and Interests of the Elderly are too principled, lacking operable norms for the purchase subject, undertaking subject, service standards, contract management, and dispute resolution, leading to unstable institutional expectations and insufficient long-term sustainability (Li 2017; Fang and Fu 2021; Yu 2017; J. Zhang 2021). The textual analysis of elderly care policies also shows that the current policy tools are unbalanced, and that the normative and binding policy tools for the legal system are insufficient. As Zhang et al. (2016) argue, the legalization of the government procurement of public services is the fundamental mechanism for the development of public services in China and an inevitable trend in building a socialist country ruled by law.

Fiscal Sustainability: Financial input has maintained sustained growth, but the long-term sustainability mechanism has not been formed. The current financial input of this purchasing system mainly relies on the general public budget, and the diversified fund guarantee mechanism of “government + market + society” has not been fully established. The financial pressure on local governments is increasing, especially in the central–western regions, where the financial capacity is insufficient, and it is difficult to maintain sustained input growth, which restricts the long-term sustainability of the service delivery system. Drawing on the experience of Japan’s long-term care insurance system, studies have pointed out the difficulty of using a single financial input model to cope with the continuous expenditure pressure brought on by the population aging, and the need to broaden financing channels through legal system design and build a diversified fund guarantee system of “finance + insurance + social capital” (Yan and Xu 2024; Y. Zhang 2024). This problem is also consistent with recent international discussions on long-term care financing. The OECD (2023) shows that long-term care spending includes both health and social components for persons who need ongoing care, while the World Health Organization (2024) emphasizes that long-term care financing commonly combines general taxation, mandatory insurance, out-of-pocket payments, and private contributions. These studies suggest that the sustainability of elderly care services depends not only on the amount of public expenditure but also on whether financing responsibilities are legally defined, predictable, and equitably distributed.

Social Sustainability: Service coverage has been continuously expanded, but there is still inequity and mismatch between the supply and demand. The current government procurement of public elderly care services mainly covers elderly people with challenges such as low income and/or disabilities while coverage of the general elderly population is insufficient. Moreover, there are serious regional imbalances in the service supply, with the developed eastern regions having complete service systems and high service quality while the central–western regions and rural areas have insufficient service supply capacities. In addition, the service content is mostly concentrated on basic life care, and the supply of services such as spiritual comfort and social participation is insufficient, which does not meet the diversified needs of the elderly. Studies have pointed out that the lack of unified legal norms for the setting of qualification conditions for service objects leads to significant differences in the accessibility of services between different regions and groups, which violates the principle of equality in the supply of elderly care services. Moreover, the weak supply capacity of elderly care services in rural areas is essentially due to the lack of special legal protection and financial support norms for these areas, which further aggravates the unfairness of urban and rural service supplies (Yu 2017; Jiang et al. 2023). From the perspective of governance, Ma (2019) emphasizes that building a complete evaluation mechanism for the quality of government-purchased pension services is particularly urgent and a driving force for realizing the modernization of the governance system and governance capabilities.

5. Legal and Institutional Dilemmas Restricting the Sustainable Delivery of Public Elderly Care Services Through Government Procurement

5.1. Fragmented Legal System and Insufficient Hierarchical Norms

The core dilemma restricting the sustainable delivery of public elderly care services through government procurement is the imperfection of the legal system. At present, China has not formulated a special administrative regulation or national unified normative document specifically for this service-purchasing model, and the core norms are scattered in the Law on the Protection of the Rights and Interests of the Elderly, the Government Procurement Law, and various policy documents, forming a fragmented legal system (Yang 2021; Wang and Wang 2021; J. Zhang 2021; Yu 2017).

A primary issue is that upper-level law provisions remain overly principled and lack operability. The Law on the Protection of the Rights and Interests of the Elderly only makes principled provisions on the government procurement of public elderly care services and does not clearly define the scope of government purchase, the qualification of undertaking subjects, the standards of service content, the rights and obligations of both parties regarding the contract, and the liability for breach of contract, leading to the lack of unified legal norms in the practice of local governments. Moreover, policies and regulations vary significantly across provinces and cities, leading to a fragmented implementation system, which damages the stability and sustainability of the system. This contradiction between the principled provisions of upper-level laws and the lack of implementation rules of lower-level laws is also the core incentive for unstable institutional expectations and inconsistent implementation standards in the practice of public service procurement, which is more prominent in the field of elderly care service procurement (Y. Zhang 2024).

Another shortcoming concerns the insufficient connection with existing legal systems. The government procurement of public elderly care services involves multiple legal departments, such as administrative, civil, and social law, but the current system does not form a coordinated legal norm system. For example, the Government Procurement Law was originally designed to regulate the procurement of goods, construction works, and services through standardized procedures, but its service procurement rules remain insufficiently adapted to welfare-oriented elderly care services. In addition, the dispute resolution mechanism for this purchasing model is not perfect, and there is no clear legal provision on whether the dispute between the government and the service provider is an administrative dispute or a civil dispute, leading to difficulties in rights protection for all parties (Ji 2020; Jiang et al. 2023).

Furthermore, local supporting regulations lag significantly behind. At present, only a few provinces, such as Jiangsu and Zhejiang, have formulated local regulations or government rules for the government procurement of public elderly care services, and most provinces still rely on policy documents to guide the practice and lack mandatory legal norms. The large differences in local regulations have also led to the fragmentation of the national purchasing system of public elderly care services, which is not conducive to the coordinated development of services across regions and the realization of inter-regional equity. Relevant studies have pointed out that the differences in norms on the access of undertaking subjects, service standards, and procurement procedures in different regions not only lead to the segmentation of the national unified market but also restrict the cross-regional development of undertaking subjects and the optimal allocation of service resources (Zou 2017).

5.2. Unsound Financial Guarantee Legal System and Insufficient Fiscal Sustainability

The sustainable delivery of public elderly care services through government procurement must be supported by a sound financial guarantee mechanism; however, the current legal system has not formed a stable and sustainable financial guarantee norm. One major gap is the absence of clear legal provisions on the proportion of this purchasing expenditure in the fiscal budget, leading to the lack of rigid fiscal input constraints. The current fiscal input of this system mainly depends on the policy will of local governments, and there is no stable growth mechanism, which leads to large input fluctuations in different regions and years and cannot guarantee the long-term sustainable supply of services. It has been proposed that the law should clarify the proportion of elderly care expenditure in fiscal budgets, and that the expenditure on elderly care services should be separately listed in the fiscal budget to realize the rigid fiscal input constraint (J. Zhang 2021; Yan and Xu 2024).

The funding structure discussed here can be divided into three categories: Government-dependent funds include general public budget appropriations, special transfer payments, welfare lottery public welfare funds, and government-funded elderly care consumption subsidies. Market-dependent funds include user co-payments, commercial long-term care insurance, service provider investment, and other revenue generated through market transactions. Social funds include charitable donations, philanthropic foundations, community mutual-aid resources, and nonprofit contributions. The current problem is that the first category remains dominant while the legal incentives and accountability rules for the second and third categories remain underdeveloped.

In addition, the legal framework for diversified fundraising remains underdeveloped. At present, the fund source of the government procurement of public elderly care services mainly relies on the fiscal budget; the legal norms for guiding the participation of social capital and charitable funds in this purchasing model are not perfect; the incentive policies, such as tax incentives, are not clear, leading to the reluctance of social capital to participate; and the diversified fund guarantee mechanism has not been fully formed. With the deepening of population aging, the demand for elderly care services will continue to grow, and the sustainability of the single fiscal input model will face substantial pressure. Relevant studies have emphasized that the tax incentives and financial support rules should be codified to guide social capital (Y. Zhang 2024; Jiang and Chen 2017).

A third weakness lies in the imperfect supervision of fund use. The current supervision of purchasing funds mainly focuses on fund use compliance, and the supervision of fund use efficiency is insufficient. There is no sound legal norm for the performance evaluation of fund use, leading to low fund use efficiency and even waste in some regions, which damages the fiscal sustainability of the system. Studies have pointed out that improving the performance evaluation system of fund use via the rule of law is the core path to improving the efficiency of fiscal fund use, and they clarify the subject, content, procedure, and result application of performance evaluation through legal norms to realize the rigid supervision of the whole fund use process (Wu 2015).

5.3. The Legal System’s Imperfect Service Standards and the Supply–Demand Mismatch

The core goal of the government procurement of public elderly care services is to meet the actual needs of the elderly; however, the current legal system lacks unified and standardized service standards, leading to a serious mismatch between the service supply and demand, which damages the social sustainability of the system. To begin with, China lacks a nationally unified service standard system. At present, there is no unified national legal norm for service content, quality, and process or evaluation criteria for the government procurement of public elderly care services, leading to large differences in the service standards in different regions and institutions, and the service quality is uneven. A legally mandated project list and standardization system is urgently needed, as well as clarification of the mandatory national standards for service content, quality, and process, to solve the problems of inconsistent service standards and uneven quality in various regions (Yu 2017; J. Zhang 2021).

Relatedly, the existing service content norms fail to address the diversified needs of the elderly. The current government procurement of public elderly care services mainly focuses on basic life care and rehabilitation nursing services, and there are few legal norms for the supply of services such as spiritual comfort, social participation, and cultural entertainment for the elderly, leading to an insufficient supply of these services, which cannot meet the multi-level and diversified needs of the elderly. In addition, the current system lacks a sound demand assessment mechanism; the government purchase of services is mostly based on the supply capacity of service providers rather than the actual needs of the elderly, leading to the problem of “what the government buys, what the elderly get”; and the matching degree between the supply and demand is low.

Recent international research supports these concerns. Song et al. (2020) show that in the government procurement of elderly care services, asymmetric information and goal divergence between governments and market-oriented providers may increase quality risks, making ex ante policy design essential. Pot et al. (2024) further emphasize that long-term care regulation requires attention to how regulatory practices are implemented in order to guarantee or improve care quality. These findings indicate that service standards in elderly care should not be limited to formal contract clauses but should include provider accreditation, care process requirements, quality indicators, inspection procedures, and beneficiary complaint mechanisms.

Compounding this problem, the qualification access rules for service providers are vague and inconsistent. The current system does not have clear and unified legal provisions on the qualification conditions, access standards, and exit mechanisms of the undertaking subjects of the government procurement of public elderly care services, leading to the mixed quality of service providers in the market. Some service providers with insufficient professional capacities and service qualifications enter the market through low-price competition, which leads to adverse selection, damages the service quality, and ultimately affects the sustainability of the service delivery system. Lu et al. (2022b) studied the quality control decision of the government procurement of elderly care services based on multi-index fusion and found that mastering relationships between quality-influencing factors and identifying key factors are beneficial for managers to make correct quality control decisions. Relevant studies have systematically analyzed the legalization dilemma of the undertaking subjects of the government procurement of public services and have pointed out that the unscientific provisions on the access conditions of the undertaking subjects and imperfect exit mechanisms are the core reasons for the uneven quality of market entities and the frequent occurrence of adverse selection problems. Thus, it is necessary to clarify the qualification conditions, access standards, and exit rules of different types of undertaking subjects through legal norms (Zou 2017).

5.4. Defective Supervision Legal System and Insufficient Governance Sustainability

A sound supervision system is the core guarantee for the standardized operation and sustainable delivery of public elderly care services through government procurement; however, the current legal system has obvious defects in the supervision mechanism, leading to insufficient governance sustainability. A fundamental defect is the unclear allocation of supervision responsibilities among multiple departments. The current supervision of this purchasing model involves multiple departments, such as civil affairs, finance, audit, and market supervision, but there is no clear legal provision on the supervision responsibilities of each department, leading to overlapping supervision and supervision gaps in practice and insufficient supervision synergy (Lin 2015; Fang and Fu 2021; Jiang et al. 2023; Y. Zhang 2024). Relevant studies have clarified the three-party supervision legal relationship in the government procurement of elderly care services and pointed out that the unclear division of supervision responsibilities among multiple departments is the core reason for the failure of collaborative supervision and the coexistence of supervision absence and offside, and that it is necessary to clarify the responsibility boundary of each supervision department through laws and establish a collaborative supervision mechanism to form supervision synergy.

Equally problematic is the unbalanced focus of supervision, which prioritizes process compliance over service quality. The current supervision mainly focuses on the compliance of the procurement process and the use of funds, with insufficient supervision of the service quality, service effect, and satisfaction of the elderly. There is no sound legal norm for the whole-process supervision of the service provision process, which leads to “emphasizing procurement and neglecting management” in practice, and service quality cannot be effectively guaranteed. Studies have pointed out that the current performance evaluation and supervision of the government procurement of public services focus too much on the compliance of the procurement process and ignore the service quality and satisfaction of service objects. The performance evaluation system should be legally reconstructed (Wu 2015). Lu et al. (2020) propose a cumulative prospect theory-based performance evaluation method for government purchases of home-based elderly care services using the Pythagorean 2-tuple linguistic TODIM method, which provides a useful reference for improving the scientific nature of performance evaluation.

Finally, the social supervision mechanism remains largely ineffective due to weak information disclosure. The current legal system does not have clear provisions on the participation of the elderly, their families, and social organizations in the supervision of the government procurement of public elderly care services; the information disclosure mechanism is not perfect, and the public cannot fully grasp the relevant information of this purchasing model, leading to the lack of effective social supervision channels. In addition, the performance evaluation system of this purchasing model is not perfect, and policymakers rarely link evaluation results to subsequent procurement or fund allocation. As the direct recipients of elderly care services, service objects are an indispensable subject in the supervision system. The existing system does not fully protect the supervision right, right to know, and evaluation right of service objects, which is the core reason for the failure of the social supervision mechanism. A robust information disclosure system is required, and complaint and reporting channels must be unblocked to protect the public’s supervision right and build a multi-dimensional supervision system (Jiang et al. 2023; Y. Zhang 2024).

5.5. Unbalanced Regional Development and Insufficient Legal Guarantee for Equity

The serious imbalance of regional development is an important dilemma restricting the sustainable delivery of public elderly care services through government procurement, and the current legal system lacks effective norms to promote the coordinated development of regions. One critical gap concerns the fiscal transfer payment system, which lacks binding legal norms. Although the new elderly care service consumption subsidy policy has established a differentiated central fiscal sharing mechanism, the current legal system does not have rigid provisions on the fiscal transfer payment for the government procurement of public elderly care services in the central–western regions and rural areas, leading to the insufficient financial capacity of local governments in underdeveloped areas. Moreover, the scale and quality of this purchasing service are far lower than those in the developed eastern regions. Drawing on the experience of Japan’s local decentralization reform, studies have pointed out that it is necessary to clarify the division of fiscal responsibilities between the central and local governments in the supply of elderly care services through laws, establish a differentiated fiscal transfer payment system, and increase financial support for the central–western regions and rural areas to alleviate the fiscal pressure in underdeveloped areas (Yan and Xu 2024).

Another missing piece is the absence of provisions for cross-regional cooperation and resource sharing. The current system does not have clear provisions on the cross-regional cooperation of the government procurement of public elderly care services, and the service resources between developed and underdeveloped regions cannot be effectively shared, which further widens the regional development gap. In addition, the legal norms for this purchasing model in rural areas are seriously insufficient, the service supply capacity in rural areas is weak, and the coverage and quality of services are far lower in rural areas than those in urban areas, which damages the service access equity between urban and rural areas. The inconsistent norms on the qualification of undertaking subjects and service standards in different regions make it difficult to realize the cross-regional mutual recognition of service standards and qualifications, which restricts the cross-regional flow of service resources and regional coordinated development. This problem needs to be solved through a unified national legal norm (Zou 2017). Zhang et al. (2022) studied the vulnerability of the government procurement of elderly care services from a complex network perspective, finding that government purchasing power and the diversity of supervisory bodies are the first priorities of vulnerability factors, which further highlights the importance of regional coordination.

6. Discussion: Legalization Pathways for Sustainable Government-Procured Elderly Care Service Delivery

This study proposes systematic legalization pathways from five core dimensions to address the institutional dilemmas identified in Section 5. The recommendations are explicitly linked to the findings: fragmented legal norms correspond to hierarchical legal construction; unstable fiscal input corresponds to fiscal guarantee rules; inconsistent service standards correspond to service standardization and demand assessment; weak supervision corresponds to whole-process supervision; and regional inequalities correspond to regional coordination and rural service guarantees.

The efficiency of government procurement in elderly care should therefore be understood as a balance between cost control, service quality, accessibility, and rights protection. Procurement may improve efficiency when service standards are clear, provider competition is genuine, and outcomes can be monitored. However, recent studies on elderly care procurement and long-term care regulation have also emphasized that price-based competition may generate quality risks where care quality is difficult to specify or beneficiaries cannot effectively complain (Song et al. 2020; Pot et al. 2024). For this reason, the reform proposals emphasize quality standards, whole-process supervision, and beneficiary participation rather than cost reduction alone.

6.1. Construction of Hierarchical Legal System to Guarantee Institutional Sustainability

As shown in Panel A of Figure 1, fragmented legal norms undermine institutional sustainability; therefore, a hierarchical legal system is the first priority of reform. To realize the long-term sustainable delivery of public elderly care services through government procurement, the first priority is to construct a systematic and hierarchical legal system and form a complete norm system with upper-level law as the core, administrative regulations as the support, and local regulations as the implementation basis (Ren and Li 2024; Wang and Wang 2021).

At the apex of the legal hierarchy, the Law on the Protection of the Rights and Interests of the Elderly should be revised. The law should clearly define the legal nature, basic principles, and rights and obligations of all parties, as well as the dispute resolution mechanism of this purchasing model in the law, to provide a unified legal basis for the national practice. At the same time, it is necessary to coordinate the connection between this purchasing system and the Government Procurement Law and to add special provisions on the procurement of public welfare services such as elderly care to adapt to the particularity of elderly care services. It has been proposed that, on the basis of revising the upper-level laws, special Administrative Measures for Government Procurement of Elderly Care Services should be formulated to make operable and detailed provisions on the whole procurement process, and special provisions on the procurement of public welfare services should be added to the Government Procurement Law to adapt to the public welfare attributes, and particularity public service procurement (Yu 2017; Y. Zhang 2024).

At the administrative regulation level, the State Council should issue dedicated regulations that make detailed and operable provisions on the whole purchasing process model, including the formulation of purchase catalogs, budget management, procurement procedures, contract management, service standards, performance evaluation, supervision and management, and legal liability, so as to form a unified and standardized operation norm for the whole country. Drawing on Japan’s legislative experience, special administrative legislation for the government procurement of elderly care services is the core measure to realize the unified standardization of the system and solve the “rule of law deficit” problem, providing unified operational norms for nationwide practice (Yan and Xu 2024). As Y. Zhang (2019) points out, strengthening legislation is the only way to realize the legalization of the government procurement of public legal services, and this logic applies equally to the field of elderly care services.

At the local level, provinces and cities must formulate supporting rules. Local governments, in accordance with the provisions of upper-level laws and regulations, combined with the actual situation of local population aging and economic development, should formulate local regulations or government rules for the government procurement of public elderly care services, refine the implementation rules, clarify the specific standards and operation processes, and form a complete legal system from the central to local level.

6.2. Improvement in Financial Guarantee Legal System to Realize Fiscal Sustainability

Panel B of Figure 1 summarizes the fiscal logic of this subsection: unstable input requires statutory fiscal responsibility, diversified funding, and stronger performance supervision. A sound financial guarantee legal system is the core foundation for the long-term sustainable delivery of public elderly care services through government procurement. A rigid fiscal input growth mechanism should be established through law. The law should mandate that procurement expenditure be included in all-level fiscal budgets, and it should clarify the proportion of this purchasing expenditure in the fiscal revenue and the stable growth mechanism, so as to ensure that the growth rate of fiscal input is not lower than the growth rates of fiscal revenue and the elderly population, as well as form a rigid legal fiscal input constraint. Procurement expenditure for elderly care services should be listed separately in fiscal budgets at all levels, and its proportion and growth mechanism should be clarified by law to ensure the rigidity and sustainability of fiscal input. Japan has clarified the proportion of financial burden of elderly care services at all levels of government through laws, realizing stable and sustainable financial input (J. Zhang 2021; Yan and Xu 2024).

Equally important, the legal framework for diversified fundraising must be strengthened, and clear legal provisions on tax incentives and financial support are essential. These policies should guide the participation of social capital and charitable funds in the government procurement of public elderly care services; encourage enterprises, social organizations, and individuals to donate to the elderly care service field; and thereby form a diversified fund guarantee mechanism. Meanwhile, it is crucial to standardize the operation mechanism of the elderly care service consumption subsidy system through legal norms; clarify the fund source, distribution standard, use scope, and supervision mechanism of the subsidy; and ensure the sustainable operation of the system. Relevant studies have suggested clarifying incentive policies such as tax preferences and financial subsidies through laws to guide the participation of social capital and charitable funds in the supply of public services, realize the “three-way win-win” situation of the government, social organizations, and citizens through incentive-compatible system design, and build a diversified fund guarantee system (Y. Zhang 2024; Jiang and Chen 2017). Zhang and Zhang (2024) also confirm that fiscal subsidies can effectively improve the technical efficiency of elderly care institutions, providing empirical support for the rational use of fiscal funds.

Finally, a whole-process legal supervision system is needed for the budget, allocation, use, and performance evaluation of purchasing funds to clarify the supervision responsibilities of financial and audit departments, strengthen the performance evaluation of fund use, and link the evaluation results with the subsequent budget allocation to improve fund use efficiency and ensure the fiscal sustainability of the system.

6.3. Improvement in Service Standard Legal System to Enhance Social Sustainability

As illustrated in Panel C of Figure 1, unified service standards, demand assessment, and provider regulation are necessary to improve social sustainability. A sound service standard legal system is essential to improve the social sustainability of the government procurement of public elderly care services and realize the precise matching between the service supply and the actual needs of the elderly (Chu and He 2018). The national standardization department and civil affairs department should jointly formulate mandatory national standards for the service content, quality, and process, the professional qualification of service personnel, and the safety management of the government procurement of public elderly care services so as to form a unified service standard system nationwide and ensure the basic quality of services. Furthermore, a project list system and standardization system for the government procurement of elderly care services through legal norms should be legally established, clarifying the mandatory national standards for services through legal norms and realizing the unified standardization of service content, quality and processes. Unified service standards and qualification standards for undertaking subjects are an important basis for realizing service quality control and promoting fair market competition (Yu 2017; Zou 2017). From the perspective of quality function deployment, Xu and Zhang (2021) propose a resource allocation approach for elderly care service, showing that staff in-home care service centers should pay more attention to improving their service attitude and quality, providing practical guidance for standard settings.

In tandem, service content norms must be expanded to cover spiritual and social needs. The government procurement of public elderly care services should cover not only basic life care and rehabilitation nursing services but also spiritual comfort, social participation, cultural entertainment, and other services to meet the diversified needs of the elderly. At the same time, a demand assessment mechanism must be embedded in legal norms, requiring the government to carry out a comprehensive assessment of the needs of the elderly before purchasing services and to determine the content and scale of the purchase based on the assessment results to realize the transformation from “supply-oriented” to “demand-oriented” service supply.

The access and exit rules for service providers also require clear legal articulation, with the formulation of clear and unified legal provisions on the qualification conditions, access standards, and exit mechanisms of the undertaking subjects of the government procurement of public elderly care services, the establishment of a strict access review system, and the elimination of unqualified service providers from the market. Furthermore, the establishment of a sound credit evaluation system for service providers that links the credit evaluation results with the government procurement qualification and establishes a mandatory exit mechanism for service providers with poor credit and unqualified service quality is required to standardize the market order and ensure quality of service. Relevant studies have systematically constructed the legalization promotion mechanism for undertaking subjects and proposed that the access conditions, qualification standards, and mandatory exit mechanisms of different types of undertaking subjects should be clarified through laws, and that a credit evaluation system for undertaking subjects should be established to distinguish between fit and unfit market entities (Zou 2017).

6.4. Improvement in Whole-Process Supervision Legal System to Strengthen Governance Sustainability

Panel D of Figure 1 presents the supervisory logic of this subsection, linking fragmented oversight to the need for whole-process supervision and stronger accountability. A sound supervision legal system is the core guarantee for the standardized operation and sustainable delivery of public elderly care services through government procurement (Fang and Fu 2021; Lin 2015). Relevant studies have clarified the three-party supervision legal relationship of the government procurement of elderly care services and proposed that the supervision responsibilities across civil affairs, finance, audit, market supervision, and other departments in the law should be legally demarcated and clearly defined, overlapping supervision and supervision gaps should be avoided, and a regular multi-department joint supervision and coordination mechanism should be established to form supervision synergy, which is the core premise for realizing the effective supervision of the whole process of the government procurement of public services (Jiang et al. 2023; Y. Zhang 2024).

Supervision should be expanded to cover the entire service provision process, strengthen the supervision of the service quality, service effect, and satisfaction of the elderly, and form a whole-process supervision system from pre-access and in-process management to post-evaluation. Meanwhile, a real-time dynamic supervision mechanism through legal norms is urgently needed, the use of digital technology to build a supervision platform is encouraged, and the whole-process traceability of service provision must be realized. To reconstruct the performance evaluation system of the government procurement of public services via the rule of law, the supervision content from the compliance of the procurement process to the service quality, service effect, and satisfaction of service objects should be expanded, and whole-process supervision before, during, and after the event should be realized (Wu 2015). Ma (2019) emphasizes that the diversification of evaluation subjects is an inevitable requirement for the diversification of governance subjects, and that third-party evaluation mechanisms should be given full play.

Moreover, social supervision mechanisms—including information disclosure and complaint channels—must be strengthened, and a sound information disclosure system should be established that requires the government to regularly disclose relevant information on the government procurement of public elderly care services, including purchase catalogs, fund use, and service evaluation results. Moreover, complaint and reporting channels should be built by clarifying the handling procedures and time limits of complaints and reports, ensuring that the elderly and public can effectively participate in the supervision. In addition, a sound performance evaluation system is needed that introduces third-party professional institutions to conduct independent evaluations of this purchasing model and link the evaluation results with the subsequent government procurement and fund allocation so as to form an effective incentive and restraint mechanism. Relevant studies have suggested establishing a sound information disclosure system, unblocking complaint and reporting channels, protecting the public’s right to know and supervise, and building a multi-dimensional supervision system combining government supervision, third-party evaluation, and public social supervision; it is also necessary to fully guarantee the supervision right of service objects, and to take the satisfaction of service objects as the core basis for contract renewal and fund allocation to form an effective incentive and restraint mechanism (Y. Zhang 2024; Jiang et al. 2023). Shen et al. (2019), in a survey of adult child caregivers of older adults with disabilities in Nanjing, found that the purchase of social care services and professional medical services for OADs significantly reduced stress, as did government-subsidized family nursing allowances, providing empirical evidence for the importance of supervision and feedback mechanisms.

6.5. Improvement in Regional Coordinated Development Legal System to Guarantee Equity

As shown in Panel E of Figure 1, regional inequality can be addressed through differentiated transfer payments, cross-regional cooperation, and targeted rural guarantees. To promote the sustainable and coordinated development of government-procured public elderly care services across China, the legal system should be improved to strengthen regional coordination and ensure equitable access. The fiscal transfer payment system requires legally binding differentiated norms. A differentiated fiscal transfer payment mechanism should increase the proportion of central fiscal sharing in the central–western regions and rural areas, reduce the pressure of local supporting funds in underdeveloped areas, and ensure that local governments in underdeveloped areas have sufficient financial capacity to carry out the government procurement of public elderly care services. Drawing on the experience of Japan’s local decentralization and fiscal transfer payment system, it has been proposed that a differentiated fiscal transfer payment mechanism should be clarified through laws to increase the central government’s financial support for the central–western regions and rural areas, reduce the pressure of local supporting funds, and ensure the fairness of the service supply between regions (Yan and Xu 2024).

Cross-regional cooperation and resource sharing should be explicitly encouraged by law. Developed eastern regions should be encouraged to carry out counterpart cooperation with the underdeveloped central–western regions through experience sharing, talent training, technical support, and other means, thereby helping underdeveloped regions improve the service capacity of this purchasing model. The law should promote the cross-regional mutual recognition of elderly care service standards and subsidies through legal norms and realize the cross-regional flow of service resources.

Rural areas, in particular, need special legal provisions to close the urban–rural gap. The development of this purchasing model in rural areas should receive increased financial support, the extension of urban high-quality elderly care service resources to rural areas should be promoted, and an integrated urban–rural purchasing system for public elderly care services should be built to narrow the urban–rural development gap and ensure equitable access between urban and rural elderly groups. Relevant studies have pointed out that one of the core reasons for the weak supply capacity of elderly care services in rural areas is the lack of special legal protection and financial support norms, arguing that the extension of high-quality urban elderly care service resources to rural areas through special legal provisions should be promoted, and an integrated urban–rural service supply system should be built (Jiang et al. 2023). Sun et al. (2022) used an evolutionary game model to analyze the synergy of health care and social care collaborative services for the elderly population in China, finding that increasing additional benefits for cooperation and reducing additional costs for cooperation can promote the willingness to synergize, which has implications for regional cooperation mechanisms.

7. Conclusions

This study systematically analyzes the current situation, institutional dilemmas, and legalization pathways of China’s government-procured public elderly care services from the perspective of legal regulation in a moderately aging society, which is closely aligned with the Laws journal’s focus on legal system construction and social governance. This study finds that China has basically formed a policy framework for this elderly care service-purchasing model, the scale of service supply has expanded rapidly, and financial input has maintained sustained growth. However, the current system still faces multiple dilemmas that restrict sustainable service delivery: the fragmented legal system weakens institutional sustainability; the unsound financial guarantee mechanism weakens fiscal sustainability; the service supply–demand mismatch weakens social sustainability; the defective supervision system weakens governance sustainability; and unbalanced regional development damages equitable access to services.

To solve these dilemmas, this study proposes five interconnected legalization measures: (1) constructing a hierarchical legal system; (2) improving financial guarantee rules; (3) establishing service standards; (4) strengthening whole-process supervision; and (5) promoting regional coordination. These measures take legalization as the core and aim to support the sustainable delivery of public elderly care services through government procurement from the institutional, fiscal, social, and governance dimensions. Moreover, they provide a legal solution for building a sustainable elderly care service system in China and offer a reference for other developing countries facing similar aging population challenges.

This study also has some limitations: due to the limitations of data acquisition, the in-depth comparative analysis of the practices of different provinces is still insufficient; in addition, this study mainly focuses on the domestic practice in China, and the comparative study of international experience is not sufficient. Future research can further deepen the comparative study of the practice of this elderly care service-purchasing model in different regions, summarize the successful experience and lessons, strengthen the international comparative study, learn from the advanced legal system experiences of countries with high aging degrees, and further improve the legal system of the government procurement of public elderly care services in China. Japan, as the country with the oldest population proportional to its total population in the world, has formed a complete legal system, a diversified fund guarantee mechanism, and a whole-process supervision system for the government procurement of elderly care services, and its legislative experience and institutional practice provide an important reference for China (Yan and Xu 2024).