Understanding the care for older people in rural China: The role of primary care providers as “the third sphere”

Context: The unprecedented trend in population aging has provoked global care crises for older adults. To address this crisis, China has launched the National Essential Public Health Services (NEPHS) program in 2009, which includes several elderly care initiatives. While existing literature acknowledges the influence of sociopolitical factors on care, it often maintains a binary perspective on the relationship between state and society, hindering a comprehensive understanding of care practices. China’s NEPHS program offers a vantage point from which to appreciate how state-society interplay shapes care practices, as well as to address the implications of socio-political factors on care.

Objective: Examining the role of primary care providers as “quasi-officials” and their care practices for older adults in “the third sphere” between the state and the society in rural China.

Setting: Community Y is a typical rural community in Northern China with a population of around 3,000 (≥ 50% of the population aged 65 and older).

Population: Older adults (≥ 65 years) and village doctors residing in Y community, along with local officials and staff involved in rural primary care delivery.

Study Design and Analysis: A three-month ethnographic study collected qualitative data through observation and informal interviews. A thematic analysis was used for data analysis.

Results: The state's care intervention through the NEPHS reshaped the multiple roles of village doctors: local doctors, businessmen, and state agents or “quasi-officials”. Their care practice was constrained by three types of constraints: the will of the state apparatus, the social networks of local society, the profit-driven market economy, all of which created a “third sphere” of care between the formal state system and the informal social system. In contrast, although older villagers seeking health care through the “third sphere” acknowledged the intention of the state and providers to provide care, the increasing sense of entitlement made them dissatisfied with the care they received and expressed a strong desire for both care and government support.

Conclusions: Village doctors in rural China strategically leverage their roles as "quasi-officials" to operate within a "third sphere", providing care solutions for the rural elderly. However, its future remains uncertain. We advise the government to engage "quasi-officials" in the "third sphere" with the primary care policy-making process in the future.