Urban Difference Perspective: Research on the Impact Effect of Home- and Community- Based Elderly Care Reform on the Resilience of Healthcare Services

Abstract Background Population aging and public health emergencies pose challenges to the sustainability of healthcare systems for older adults. This study aims to assess the resilience of urban healthcare system for older adults and to examine whether, how, and under what conditions nationwide reforms in home and community care have enhanced the resilience of this system. Methods Using the pilot program for reforming home- and community-based elderly care services (PHC), rolled out in five batches from 2016, as a quasi-natural experiment, we analysed 4774 city-year observations from Chinese prefecture-level and higher cities over 2010–2024. The urban healthcare services resilience index (LCRI) is constructed from two dimensions: service supply resilience and cost guarantee resilience. Spatial analysis, kernel density estimation, and Dagum Gini decomposition characterised its distributional evolution and regional disparities. A staggered difference-in-differences (DID) model identified the average treatment effect, dynamic effects, and transmission mechanisms, with multiple robustness tests. Results During the sample period, the overall urban LCRI rose steadily, areas with low LCRI values contracted significantly, and regional disparities showed a fluctuating trend toward narrowing. Its spatial distribution did not exhibit a typical “higher in the east, lower in the west” gradient, but rather varied more in accordance with population density. PHC significantly improved the LCRI, and the policy effects gradually emerged and continued to accumulate as PHC progressed. Mechanism analysis indicates that PHC primarily exerted its effects by stimulating healthcare supply and strengthening cost coverage, as evidenced by an increase in the number of seats for community meal assistance services and care personnel, as well as a decrease in per capita healthcare expenditure. Heterogeneity analysis shows that the effects of PHC were more evident in cities with higher degrees of economic development, more advanced aging populations, abundant medical resources, well-developed digital infrastructure, and greater fiscal capacity. Conclusions PHC can enhance the LCRI by stimulating healthcare supply and strengthening cost coverage, with gains accumulating over time and concentrated in better-resourced cities. This study provides evidence at the urban level for enhancing the resilience of healthcare systems for the elderly.