Hanhua Wang, Shijie Lin, Yingying Ji
The negative within-county association between fiscal self-sufficiency and CCD reveals a "fiscal paradox": periods of higher fiscal autonomy are accompanied by a relative under-prioritization of older adult care beds, creating a structural imbalance, whereas greater reliance on conditional transfers is associated with more balanced resource allocation. These findings generate the hypothesis-meriting further testing with direct transfer data-that conditional intergovernmental transfers may help promote balanced resource allocation, and that coupling indicators embedded in transfer designs could warrant evaluation in future policy pilots.
OBJECTIVE: While population aging intensifies the need for integrated health and older adult care, it remains unclear whether greater local fiscal capacity actually facilitates such coordination. This study examines the coupling coordination between healthcare resources and older adult care beds at the county level in Ningbo, Taizhou, and Wenzhou (Zhejiang, China) from 2022 to 2024, with a focus on the role of fiscal constraints.
METHODS: A panel of 31 county-level units (N = 93) was constructed. A coupling coordination degree (CCD) model was used to measure the structural coordination between the healthcare subsystem (beds, physicians, and registered nurses per 1,000 registered population) and the older adult care subsystem (older adult care beds per 1,000 registered population). Factors associated with CCD were examined using a two-way fixed effects panel regression with county-clustered robust standard errors.
RESULTS: The mean CCD was 0.419 (SD = 0.166), indicating a state between "near disorder" and "barely coordinated," with no significant temporal trend. The aging rate was positively associated with CCD (β = 0.128, p = 0.027). Counterintuitively, fiscal self-sufficiency exhibited a significant negative within-county association (β = -0.00181, p = 0.014): periods of higher own-source revenue reliance within a county were accompanied by lower coordination. GDP per capita and urbanization rate were not statistically significant. Robustness checks confirmed these findings.
CONCLUSION: The negative within-county association between fiscal self-sufficiency and CCD reveals a "fiscal paradox": periods of higher fiscal autonomy are accompanied by a relative under-prioritization of older adult care beds, creating a structural imbalance, whereas greater reliance on conditional transfers is associated with more balanced resource allocation. These findings generate the hypothesis-meriting further testing with direct transfer data-that conditional intergovernmental transfers may help promote balanced resource allocation, and that coupling indicators embedded in transfer designs could warrant evaluation in future policy pilots.