We analyze the socioeconomic and political contextual determinants of the burden of disease attributable to three metabolic risks in children: kidney dysfunction, high fasting plasma glucose, and high body-mass index. We use data from 121 countries. We matched data of the Global Burden of Disease project, World Bank and United Nations databases. The burden of disease is measured with the Disability Adjusted Life Years lost. We explore associations with four groups of variables: (i) income level, which measures differences in socioeconomic conditions between countries; (ii) income inequality, which measures within country inequalities in the income distribution; (iii) health care expenditure, which measures the resources allocated to health and healthcare, and (iv) women empowerment, which we measure in terms of both educational and political participation. Our findings point toward the need to act at the root of the underlying factors underpinning the disease burden, namely: reducing between and, particularly, within-country income inequalities, increasing the role of expenditure on health, and ensuring women empowerment and girls education. To our knowledge, this is the first study that have identified the associations of these variables with the burden of disease that is specifically attributable to metabolic risks in childhood. Improving childhood health is a key goal worldwide and essential to promote and enhance adult health. While children mortality rates have decreased dramatically over the last decades , the risMost of these risk factors with growing prevalence during childhood play a large role in explaining overall population ill health. The Global Burden of Disease (GBD) project estimates that globally in 2019 61.9% (95% IC 59.8–63.9%) of the deaths and 48.1% (95% CI 45.3–50.1%) of the Disability-Adjusted Life Years (DALYs) were attributable to known risk factors , and high body-mass index (BMI)In this paper we analyze the socioeconomic and political contextual determinants of the burden of disease attributable to metabolic risks in children using data from 121 countries. We explore the impact of four groups of variables: (i) income level, which measures differences in socioeconomic conditions between countries; (ii) income inequality, which measures within country inequalities in the income distribution; (iii) health care expenditure, which measures the resources allocated to health and healthcare, and (iv) women empowerment, which we measure in terms of both educational and political participation. This is an observational ecological retrospective study for 121 countries.We compiled information from three sources of data: (i) the GBD project databaseWe analyzed three dependent variables that measure the rate of DALYs in children attributable to kidney dysfunction, high FPG and high BMI, respectively. For each variable, we conducted separate linear regression models by age intervals: 0 to 5, 6 to 9, and 10 to 14 year-old. Independent variables included: (i) income group as defined by the World Bank classification into low, lower-middle, upper-middle, and high-income countries; (ii) income inequality, measured by the Gini index which ranges from 0 to 100, where 0 represent perfect equality and 100 represents perfect inequality; we created a binary variable indicating whether the country belongs to the most unequal quartile ; (iii) resources allocated to health and healthcare, measured by health expenditure as a share of total government expenditure; and (iv) women empowerment, measured by the ratio girls/boys in primary, secondary, and university education and by the percentage of seats held by women in national parliaments. p-values equal or under 0.05 were considered strongly significant, while p-values equal or under 0.10 were considered weakly significant.We conducted multivariate ordinary least squared (OLS) models and reported standardized coefficients, which allow the comparison of the relative importance of each independent variable in explaining the dependent variables. Coefficients with associated We checked the assumptions of the linear regression model. Multicollinearity among independent variables was explored with the Variance Inflation Factor (VIF), with values higher than 10 indicating a multicollinearity problem . Ramsey We found no evidence of multicollinearity issues. The maximum VIF in the linear models is 5.60 (for high income countries), and the mean VIF is 2.66. Linear models for all age groups on kidney dysfunction and on FPG for the youngest age group had no evidence of misspecification errors. In contrast, models for obesity passed the Ramsey Reset test only after the inclusion of health expenditure in quadratic form. We could not identify well-specified models on FPG for the older age groups at a 5% significance level, however, the null hypothesis that the linear models were well-specified could not be rejected at a 1% significance level. We found evidence of heteroskedasticity in nearly every model, and therefore we reported robust standard errors in every case. The assumption of nonnormality of errors was rejected in every model, but after the results of misspecification tests, we considered the model inference as asymptotically valid . Given tWe observed a strong and significant income gradient in the burden of kidney dysfunction among children in every age group. The income category variables had the largest relative importance in assessing differences in the disease burden attributable to this metabolic risk across countries, followed by the income inequality variable. This latter variable was significant in models that focused on the burden among 6 to 9 and 10 to 14 years-old children, and suggest that countries with the highest levels of income inequality experience a larger burden of disease attributable to kidney dysfunction in these age groups, even after controlling for the absolute income level. The share in health spending had not a significant association with the burden due to kidney dysfunction in children, but some indicators of women empowerment were identified as negatively associated, either weakly or strongly significantly, with the burden of kidney dysfunction in every age group; particularly, the ratio girls/boys in primary education and the percentage of women holding seats at the country parliament.In the case of the burden due to high FPG in childhood, we observed a strong and significant income gradient among the youngest children groups. Income inequality had a weakly significant association in the youngest and oldest age groups, and also pointed toward the most unequal countries suffering a higher disease burden associated with high FPG. In addition, the models showed that a higher share of total public expenditure allocated on health and health care was associated with lower burden of FPG among children. This variable was found to be strongly significant at the two oldest age groups. Some indicators of women participation in education were weakly associated with the burden attributable to high FPG among the youngest children, which in the case of FPG were related to the ratio girls/boys in primary and secondary education.The socioeconomic and contextual determinants of the burden attributable to obesity in childhood showed some different patterns. The income gradient was either non-present or had a reverse relationship, indicating that in high income countries the burden associated with high BMI is larger than in other countries for the oldest children. Income inequality has a positive and significant effect at every age group, which suggest that, similarly to that observed in the other risk factors, independently of the country level of income, the most unequal countries experience a higher disease burden attributable to children obesity. However, the association of health spending with obesity was found to be non-linear, showing that at low levels of health spending, increases in this variable were associated with decreases in the obesity burden, while at higher levels of health spending the association turned positive see . We willIn this paper we have analyzed the determinants of disease burden attributable to metabolic risk factors in childhood. Our results showed complex and varying socioeconomic and contextual patterns. We observed that while kidney dysfunction and high FPG had a strong income gradient-indicating that poorer countries experienced a disproportionately higher burden associated with these metabolic risks, the opposite was true for the burden attributable to high BMI among older children. However, the finding that income inequality was positively associated with disease burden was consistent across the three analyzed risk factors, albeit of being only weakly significant for high FPG. Higher shares of public spending allocated to health were found to be negatively associated with the burden of disease attributable to high FPG, while the relationship with the obesity burden was found to be non-linear. Women empowerment indicators were found to be negatively correlated with the disease burden attributable to high FPG and kidney dysfunction.Among the three metabolic factors analyzed in this study, obesity is mostly a consequence of behavioral risks, such as unhealthy diets and sedentarism, which mainly characterized richer economies . On theThe strong and consistent finding that the most unequal the country the higher the burden of disease associated with each metabolic risk analyzed in this study is striking. It highlights how, over and above the absolute income level of a country, within-country inequalities are main drivers of disease burden in childhood. This finding emphasizes the need to prioritize efforts at reducing income inequalities, on top of ensuring economic growth, in order to reduce the development and consequences of metabolic risks factors in children. Finally, the findings that indicators of women empowerment might act as protective factors for the burden of some of the risk factors analyzed in this study is also crucial. This result supports the claim that, aside from its own value, empowering women may improve women's own health and also that of the next generation . The absThis study has a number of limitations. First, we have analyzed three metabolic risk factors which are measured to be directly attributable to the burden of disease in children. However, other key metabolic risk factors include high LDL cholesterol, high SBP and low bone density mineral. While these three metabolic risk factors are not directly attributed to deaths and DALYs in childhood, they play an indirect effect due to the interrelated associations between them and other risk factors. For instance, obesity is associated with high SBP, high FPG and high LDL cholesterol, and high SBP is both a cause and a consequence of kidney dysfunction. Therefore, there are several interrelationships between these metabolic risk factors. In addition, we have used data for 2019 and from 121 countries. Establishing causal relationships using cross-sectional ecological data is challenging for two main reasons. First, our independent variables might be correlated with a number of factors that also affect children disease burden, and this might bias our estimates due to unobserved country-level heterogeneity. And secondly, the ecological nature of the data implies that attention is needed when trying to generalize findings based on comparisons across countries to the population within the countries. Nonetheless, we have been able to identify strong associations between several socioeconomic and contextual factors and the burden attributable to metabolic risk factors in childhood.In summary, in this study we have investigated the determinants of the disease burden attributable to metabolic risk factors in children, and we have found several socioeconomic and contextual patterns. Our findings point toward the need to act at the root of the underlying factors underpinning the disease burden, namely: reducing between and, particularly, within-country income inequalities, increasing the role of expenditure on health, but also that of other public measures, and ensuring women empowerment and girls education. To our knowledge, this is the first study that have identified the association of these variables with the burden of disease that is specifically attributable to metabolic risks in childhood. Given the large role that metabolic risks play at the population disease burden, reducing the onset of and alleviating the consequences of metabolic risk factors early in life will significantly reduce the overall population disease burden.https://www.healthdata.org/results/gbd_summaries/2019), the World Bank repository (available from: https://data.worldbank.org/), and the United Union repository (available from: http://data.un.org/).Publicly available datasets were analyzed in this study. This data can be found at: the Global Burden of Disease repository , with the support of COST (European Cooperation in Science and Technology) and the Horizon 2020 Framework Program of the European Union.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Corruption and inefficiency of public funds pose a risk in public administrations. This paper analyses the corruption risk at the local level by analysing indicators of public procurement contracts in four deputations of Galicia (Spain). In addition, the pandemic has created opportunities to increase this risk and the misuse of public funds given the need to act quickly. Therefore, the study analyses whether the Covid crisis led to significant changes in expenditure in the four deputations and whether it involves a higher use of minor contracts, an award procedure without publicity or bidding, which has been found as increasing corruption risk. The effects of corruption are considered among the most damaging at the local government, which is the closest level of government to citizens  in Spain, analysing their corruption risk. This topic has hardly been approached in literature; however, there is a growing interest in this issue, given the extraordinary situation arising from the Covid 19 pandemic. It affects procurement and economic procedures, as well as the management of a substantially increased volume of public funds. The results contribute to the debate on how the pandemic led to an increased corruption risk in local public procurement.The analysis of Spanish local public administration represents a worthy case study for diverse reasons. Firstly, Spain has been severely affected by the pandemic and forced to give a quick response. Secondly, the analysis of Spanish local government is interesting because of the high level of decentralisation and asymmetric regionalism. The multilevel organization of the Spanish public administration involves challenges for governance and the need for effective coordination to manage the emergency. Thirdly, the Spanish intermediate governments (deputations) face difficulties considering the dimension of accountability because they are entities focused on expenditure and characterised by the lack of own revenue-raising capacity. Fourthly, there is a diversity of responses to the Covid emergency at the local level, in particular, in the deputations, derived from the flexibility in the execution of its competences. Although deputations have limited competences, these competences are vague and can be executed with a certain degree of discretion. All this makes it interesting to study how they managed the emergency resulting from covid.Methodologically, this paper combines a literature review and legislation analysis with non-parametric data analysis of minor public procurement contracts. Changes in minor public procurement contracts in the four deputations derived from Covid are specifically analysed. Four deputations from the same region  are selected because they show several patterns of management and different responses to the emergency. The study focuses on the awarding procedures and awarded companies in the period 2018–2021.This paper is organised into five sections, apart from this introduction. The second section approaches the theoretical framework about corruption risk in the Covid context in public procurement. The third section describes the role of the deputations, their competences, and the minor contract as recurrent expenditure. The fourth section analyses the evolution of their spending in the pandemic, as well as the corruption risk that they face. The fifth section examines the corruption risk through indicators of local public procurement focusing on the effect of pandemic, after explaining the methodology and the analysed data. Finally, conclusions and recommendations are presented.Public procurement is one of the government tools available for achieving public goals, accounting for around 10% of Gross Domestic Product in Spain OECD, . It has Direct award and, specifically, minor contracts are one of the most relevant types of public procurement. This fact is not unique to Spain, as the direct award is a method also abused in the EU Member States. Thus, for example, 90.2% of the number of contracts are directly awarded in Portugal, representing 47.9% of all public procurement expenditure Telles, . The feaIn addition to these usual risks, the exceptional situation resulting from the pandemic could have created more opportunities for the misuse of public funds , provinces (50), and municipalities . In addition, the deputation is the government and administrative body of a province, which is composed of municipalities. Each of these types possesses autonomy for the management of their interests. Most of the municipalities (91%) have less than 10,000 inhabitants. This hinders the implementation of certain public policies because they require a broader territorial scope, given the lower costs of the aggregated provision or the insufficient resources to undertake them by a single municipality Jiménez, .Intermediate local governments, such as the deputations (NUTS 3), play a key role in this structure. Their role is to enhance cooperation to municipalities, especially those with less economic and management capacity, and to ensure the provision of the minimum services entrusted to them.The representatives of the intermediate government (deputies) in Spain are not directly elected by the citizens, but by the representatives of the municipalities that compose the province (councillors). Thus, citizens do not have a candidate to vote for but elect the councillors of the municipalities, who appoint the provincial deputies among themselves. This system means that accountability to the electorate, who often do not even know their representatives, is neither operative nor effective FHD, . This laThe deputations can procure through several types of contracts according to different criteria, such as the object , the procedure  or the award method (open or negotiated). The rules to be followed for publication, awarding, or deadlines, among other aspects, change from one typology to another.Public procurement must comply with the principles of free access to tenders, publicity and transparency of the procedures, and non-discrimination and equality of treatment among suppliers. The law regulates a series of award procedures that aim to fulfil these objectives and avoid corruption. The open procedure and the restricted procedure are set as the ordinary and preferential procedures. Moreover, the law indicates other procedures restricted to certain (extraordinary) cases, such as the negotiated procedure, competitive dialogue, the innovation partnership, or minor contracts.Minor contracts are intended to allow the Administration to procure products and services on a lower scale in a more agile way. The estimated value of this contract should be less than 40,000 euros for works, or 15,000 euros for supply or service, while there is no quantitative limit for the access to databases and subscriptions to publications. The duration may neither exceed one year nor be extended.In this type of contract, given its relatively small scale, a large part of the formalities required in overall award procedures can be neglected. Thus, the expedient in the contracting body merely requires reporting the need for the contract and that it is not unduly splitting, approving the expenditure, and incorporating the corresponding invoice, as well as the budget in the case of works contracts.Carrodeguas  considerMoreover, minor contracts can be directly awarded, being one of the most widely used forms of procurement in Spain, rather than an exceptional procedure. A report of the Consello de Contas  notes thThe direct award may be effective and necessary on certain occasions. Opposite to this simplified procedure of minor contracts, the open procedure means that the tender announcement is published in the contracting entity profile, and anyone can submit a proposal. It is neither a simple nor a short procedure, as it lasts at least six months, but it ensures transparency, and objectivity Royo, .Nevertheless, the problem arises when their use is abusive and sometimes self-interested. Direct award does not require competition or advertising. This implies a lack of transparency, which can favour corruption and economic inefficiency , the amount of many of these supplies and services contracts also changed. It raises the crucial question of whether there was overpaying or if there are suppliers willing to accept lower payments to maintain contracts, as Belmonte and Cabo  pose.Moreover, actions of a necessary, repeated, and expected nature or the performance of services of a similar nature that respond to a single purpose are separately awarded. Indeed, multiple contracts are awarded to the same supplier  or by observations that stand out for another cause, a 'Median Absolute Deviation' (MAD) Analysis is performed. MAD Analysis, proposed by Leys et al. , tests wA relevant aspect regarding the analysis of the budgets is to study whether changes occurred to adapt to the Covid context. To this end, Table Table For the 2021 budget year, expenditure is still being processed. It should be noted that for the preparation of the 2021 budget, the situation resulting from Covid has already been considered. Table The analysis of these data suggests that part of the spending of Galician deputations reports in 2020 a statistically significant increase compared with previous years. However, it was not found evidence that Galician deputations have substantially modified their budget distribution.Anyway, rather than examining significant changes in spending amount or distribution, it is more relevant to analyse how spending is executed and how procedures are being managed. In this sense, spending can be allocated through faster procedures and under less control in times of pandemic. This fact entailed higher opportunities for corruption risk, as previous literature highlighted  at the national level, the information service established by each region, or their local transparency web portal. In this sense, the lack of homogeneous data about minor contracts, and reusable information publicly available about the local public procurement hinders transparency and control. This is a factor that can affect accountability and the fight against corruption Jiménez, . In thisThe information for Deputation of Ourense was obtained from the Public Procurement Platform. However, the information provided on this portal for the other three deputations was not complete. As an illustrative example, the Deputation of Lugo had only 11 minor contracts registered from 2018 to September 2021, while 3,407 contracts were identified on their transparency portal. Given the lack of systematised information, for this analysis an own database is developed, including information from both sources: national and local portal webs. All this information is refined, checking for homogeneity and eliminating duplicities.As a first step to assessing corruption risk in local public procurement and the effect of pandemic, this section focuses on local minor contracts. This issue is relevant for corruption risk, given the significant percentage of minor contracts in the total value of contracts, the features of these contracts ;Total amount awarded;% contracts awarded to the 10 companies with the most contracts out of the total number of companies;Total amount awarded to the 10 companies with the highest number of contracts;% Amount awarded to the 10 companies with the highest number of contracts awarded;Amount to 5 largest awarded companies;Amount to 10 largest awarded companies;% Amount to 5 largest awarded companies out of total awarded amount;% Amount to 10 largest awarded companies out of total awarded amount.Despite concentration is a single dimension, diverse indicators regarding minor contracts are considered in this analysis. Robust indicators for assessing corruption risk require a methodology that allows to discuss observations on several variables. This procedure is followed by different international indicators, such as the Corruption Perceptions Index or the Corruption Watch. Therefore, a non-parametric analysis of the following indicators is also carried out:This section presents the results obtained with the MAD methodology on corruption risk. The methodology is suitable when the number of observations is limited and it is consistent with other relevant literature Heeks, .Table Among direct awards, the most common object of the contract is public works in the case of Ourense, while are services in Lugo Table . It is nTable The analysis has not found excesses in the amount thresholds established by law to be issued as minor contracts, except for few cases in the four deputations. One relevant detail of the study of minor contracts is that several contracts, mostly of a public works nature, are very close to the 40,000 € threshold in the Deputation of Ourense. Contracts awarded to the same supplier in the same year for the same amount for different work items are also observed. Thus, it is common to find contracts for 39,669.42 € with different concepts, such as "rehabilitation of public service buildings"; "paving or improvement of infrastructures". In most cases, the difference in the object of the contract arises from the municipality in which the work is undertaken. However, there are cases where activities of very similar objects are carried out in the same municipality. Concerning equal award amounts from several suppliers, a clear example is that 24 different suppliers were granted 39,669.42 € in 102 contracts in 2020. This is consistent with Belmonte and Cabo , where cTo summarize, a set of indicators used show the concentration of awardees and resources in minor contracts. It should be noted the number of contracts with a value close to the threshold, and this trend increases during the pandemic. The results show a higher corruption risk in those deputations that mostly (over)use this type of public procurement. The higher spending executed through minor contracts and simplified processes is consistent with Rose-Ackerman  researchCorruption at the local level is especially relevant, due to its direct effect on the local economy and closeness to citizens. As it is difficult to measure corruption at the local level, corruption risk is considered as a variable for approaching corruption at this level. The corruption risk does not inexorably imply corruption, but it does increase the probability that this event occurs. It should be noted that corruption risk has an impact on economies, because it derives from issues such as lack of confidence in the system, less transparency, and lower economic efficiency.This paper deals with the corruption risk in local public procurement and the potential increase of this risk during pandemic. The Covid emergency results in speeding and loosening of procedures, which undermines transparency and hinders control.This research focuses on minor contracts, a common type of public procurement, which allows circumvent ordinary procedures. Minor contracts avoid several formal issues, involving less transparency, publicity, and competition. This increases the opportunity for the misuse of public funds and enlarges corruption risk, leading to economic inefficiency. In addition to the inherent characteristics of minor contracts, the pandemic situation intensifies the risk.The misuse of minor contracts often includes contracts just under the threshold or contracts awarded separately to the same contractor for recurrent actions or the same object, which suggests unduly splitting. The awarding of several contracts could also be due to poor procurement planning.To analyse the corruption risk during the pandemic, this paper uses the case of the deputations, an intermediate level of government in Spain (NUTS 3). The deputations present peculiar characteristics that make them worthy of study. Thus, they act subsidiarily to entrust the provision of services in municipalities in a framework of limited and diffuse competences. They face difficulties for accountability given their lack of own revenue-raising capacity and that their government is not directly elected by citizens. These problems for accountability can also increase corruption risk in the local governments. Four deputations in the same regional context  are selected because they show heterogeneity of responses to the pandemic and spending instruments at the local level, which enriches this contribution.To measure the corruption risk in local public procurement, this paper proposes several indicators of concentration concerning minor contracts, such as of the number of contracts, amount, and suppliers. The link between concentration and higher corruption risk is suggested by literature Heeks, .The empirical analysis shows that deputations budgets have increased during 2020, due to the pandemic shock. However, the execution of spending shows different patterns among the four deputations analysed. Those deputations, which have traditionally allocated the most resources through minor contracts (Ourense and Lugo), have increased their use of this kind of public procurement. They present a higher corruption risk, as the different indicators of concentration suggest. The minor contracts for public works are overused by the Deputation of Ourense during 2020. Moreover, the number of contracts just at the thresholds has increased, as well as concentrated on a few suppliers and even on the same contractor on several occasions.Overall, the study of the indicators regarding the concentration of minor contracts in the four deputations shows a higher concentration during pandemic both in resources and suppliers. This trend suggests a higher corruption risk in a singular context when public funds have increased, and the procedures have loosened.This research contributes to the existing literature about corruption risk at the local level focusing on minor contracts. In addition, it analyses the effect of the pandemic, providing evidence of different response patterns by local governments. This heterogeneity leads to a differentiated impact on corruption risk. The context poses new challenges for local public procurement, which calls for a new framework to ensure transparency and efficiency, as Anessi-Pessina et al.  underlinBased on the analysis carried out, this paper proposes some recommendations. Local public procurement should be carried out through procedures that ensure transparency and competition, in line with the Consello de Contas . TherefoThe main limitations of the study lie in the available data and the lack of homogeneity. Another limitation is the short time horizon since the outbreak of the pandemic emergency. This does not allow to assess whether the perceived changes are structural or arise from the current circumstances.The future extensions of this research aim to delve deeper into the approach of a corruption risk indicator through factor analysis. It would also be interesting to widen the study for all Spanish deputations. Another interesting question is to study the association between the corruption risk and the cases of corruption in court or how the risk of corruption affects local and regional development.


As Chinese population ageing becomes increasingly severe, the disjunct between supply and demand for pension services is becoming increasingly serious. The development of elderly care social enterprises plays an important role in solving this disjunction. Such development comes from both the enterprise’s own capacity building and from external support. There are abundant studies on the capacity-building of pension social enterprises in the existing literature, but there are relatively few studies on their external support. In order to better study the external support of elderly care social enterprises in China, we adopted the case study method; we selected GY  as a case study according to certain criteria, and we conducted a series of discussions. Firstly, an analytical ‘government-society-family’ framework was constructed. Second, it was argued that there is insufficient external support for elderly care social enterprises. At the government level, there is a lack of policies, difficulties in implementation and significant geographical differences; at the social level, there are weak support platforms and lack of community supports; and at the family level, there are constraints in regard to traditional concepts and the ability to pay. Finally, an external support system of Chinese elderly care social enterprises was constructed to help more elderly care social enterprises overcome the lack of external support in the development process. Social enterprises have attracted widespread attention in recent decades ,2 and haIn China, with the increase of population aging, elderly care faces a series of challenges. The sector’s single dependence on the government has been unable to meet the growing demand for pension services, and the enthusiasm of social capital to enter the pension service industry needs to be improved . The oveMany studies have been conducted on the sustainable development of social enterprises ,19,20. HThis research makes three contributions to the literature. First, it constructs a government-society-family analytical framework that provides new insight for future elderly care social entrepreneurs into creating new enterprises or promoting the sustainable development of enterprises. Second, as China is experiencing serious population aging, experience in the development of elderly care social enterprises can provide a reference for other developing countries facing the same difficulties or problems. Finally, external support research on elderly care social enterprises can provide a reference for social enterprises in other industries. Only by paying attention to external support and adjusting internal strategies in a timely manner can the sustainable development of social enterprises be achieved.A social enterprise is a business activity that is driven by a social mission ,24, whicThe second aspect is relatively weak regarding garnering people’s attention. Funding sources have a significant impact on the survival and development of social enterprises, thereby making them more dependent on government grants and donor funds, especially in the early stages of creation . InstituJian, et al. used a content analysis approach to study health organizations seeking social support, including informational, emotional, and instrumental support, through social networking sites . In BerlIn short, the existing literature on social enterprise support research is still quite weak, because it mainly focuses on how to maintain the balance between a social mission and its financing with single support, such as local government support, i.e., the research lacks a comprehensive discussion of support systems. We believe that it is not enough that the support needed for the sustainable development of social enterprises only comes from financial support. It also needs more support from other sources, and it is better to form a support system.Through a literature review, it is found that the existing research on the support of social enterprises has been focused on the specific field of elderly care social enterprises. Furthermore, there is a lack of unified analysis framework in the research process. Therefore, to better study the external support of elderly care social enterprises, we used welfare diversity and social support theory to build an analytical government-society-family framework of external support for elderly care social enterprises.After the 1980s, many countries around the world experienced a policy shift in the provision of basic services. In many developing countries, the private sector, including civil society- and community-based organizations, has been recognized as part of the formal welfare system . The terWelfare diversification can be seen not only as a way of maintaining or supporting pluralistic systems but also as a way of at least partially replacing the state as a service provider. Welfare pluralism refers to social and health care being provided by four different sectors: the statutory, voluntary, commercial, and informal sectors. The state plays an important role in welfare provision but does not have a monopoly on welfare, which should be provided by the whole society  . Olsson,Research on social support was first proposed in the field of psychology. Durkheim used social support to investigate the physical and mental health of individuals. Later, social support was introduced into the field of psychiatry. In both areas, the main concern was the relationship between social support and physical illness, psychological disorders, mental illness, quality of life, etc. ,54,55,56Clark et al. considered social support to be the help provided by family members, relatives, friends, and neighbors , and WorThe theory of welfare pluralism comes from the reform of the European welfare system. It is generally recognized as containing are two important concepts: decentralization and participation . DecentrElderly care social enterprises are gradually taking their place as hybrid organizations in the field of social welfare. Sud et al. argued that social enterprises, like every new type of organization, must be accepted politically and socially. The existence of certain types of organizations depends on the support of the society in which they are located . StudiesThe previous review of social support and welfare pluralism theory shows that social support includes a support subject and a support object. The support subject can be a person’s informal network, such as family, friends, and colleagues, or formal network, such as health care professionals and human service workers , and supFor this article, we adopted a qualitative case study approach and selected a potential elderly care social enterprise , which is called GY in this paper. Starting from the three-dimensional government-society-family framework, this paper explored external constraints on the development of China’s geriatric social enterprises and at the same time aimed to identify relevant external support to ensure the sustainable development of geriatric social enterprises. In other words, we investigated what kinds of factors constrain sustainable development and how to achieve sustainable development through external support for enterprises. The question of how is well suited to the case study approach . In the First, there are certain recognized characteristics of a social enterprise. Although there is no uniform definition of a social enterprise, different countries have different understandings of social enterprises. However, generally speaking, social enterprises are seen both as a powerful complement to government, market and nonprofit organization failures in some areas, and as businesses that use business models to solve social problems and create social value, while maintaining a strong sense of social mission and social responsibility.Second, the social enterprises examined in the current study provide elderly care services; thus, other types of social enterprises are not within the scope of this study. There are many fields of social enterprise services, such as those pertaining to children and youth, barrier-free services, rural development, ecological protection, elderly care and so on. Given that there are differences between the different fields of social enterprises, we only focus on the field of elderly care of social enterprises. These enterprises will be collectively referred to as elderly care-oriented social enterprises. Their service objects are mainly elderly individuals and their families, and their function is mainly to provide various long-term or short-term old-age care services, such as life care, medical care, spiritual comfort, emergency relief, breathing services, home services, and so on.Third, there in the problem of time malleability. Time span is a very important factor in the sustainable development of social enterprises. The GY is a representative of the three types of social enterprises for the elderly population that meet the above mentioned three criteria.With the help of the Civil Affairs Bureau, we got a list of 12 better elderly care enterprises. Then, according to the above three standards, we finally chose GY. According to Standard 1, two enterprises were excluded; according to Standard 2, three enterprises were excluded; according to Standard 3, six enterprises were excluded.The GY was founded in 1999 and has been developing for more than 20 years. In 1999 the government began to allow social capital to enter the field of elderly care. The first private elderly care institutions in our country were established in 1999; the current Chinese population ageing problem also began in this year. Prior to 1999, care services for the elderly population were basically carried out by the children in a family; thus, the demand for socialization of care services for the elderly population was not strong. At this point, China’s elderly care services did not cause widespread concern within the community or serve as a social problem. As the country entered the current year of population ageing, families began to increasingly struggle to provide care for their elderly relatives. The rigid demand of China’s elderly care services was seriously insufficient, which caused widespread concern from all walks of life. In this context, the elderly care industry began to develop.In its initial period, the GY was a simple private enterprise for the aged, which mainly provided life care service for the aged with disabilities and mental handicaps and cooperated with hospitals to provide medical rehabilitation service. During this period, the GY had 60 beds and offered the concept of integrated care. At that time, due to the lack of corresponding policy system and the support of relevant departments, the implementation of integrated care concept was very difficult. In 2003, the GY was transformed into a public-funded private pension enterprise that was supported by government infrastructure; the number of beds increased to 106.In 2011, under the guidance of national policy, the GY began to explore the chain operation model, and successfully created a second retirement home. Thus far, there are 12 chain organizations. The chain’s geographical area covers the southern, northern, and central areas of Jiangsu Province. At the time of the opening of the second institution, the GY put forward its social value concept of providing high-quality services for elderly individuals at low cost; these services included personal health care, diet and personal care, home health care and social and recreational activities. The GY also regularly participated in the community to carry out free health check-up activities, thereby going as far as possible to solve the problem of unattended elderly individuals. Thus, the GY had begun to pursue the dual goals of social enterprise.However, in China at that time, the perception of social enterprise was very vague. On 3 June 2011, the ninth plenary session of the 10th Beijing Municipal Committee of the Communist Party of China adopted the “Opinions of the Beijing Municipal Committee of the Communist Party of China on Strengthening and Innovating Social Management to Promote Social Construction in an All-round Way”, the third part of which encourages localities to “actively support the development of social enterprises and vigorously develop social service industry”. This was the first mention of social enterprises in official documents. On 11 November 2016, the General Office of the Communist Party of China Beijing Municipal Committee Beijing Municipal People’ s Government issued “Beijing’s 13th Five-Year period of social governance planning”, in which the third part of the fourth article clearly points out that one should “vigorously promote the development of social enterprises focusing on serving the people’s livelihood and carrying out public welfare”. On 23 April 2018, the Chengdu Municipal Government promulgated the “Opinion on Cultivating Social Enterprises for Community Development and Governance”, which was the first relevant policy specifically targeting social enterprises. Thus far, this is the only document specifically aimed at social enterprises; there is no similar national document or guidance at the specific practical level.There are many geriatric care social enterprises, or potential social enterprises, in the field of practice that are like the GY. The main reason for calling the GY a potential social enterprise is that the status of their social enterprise is not clear. Although the GY has been practicing the dual goals of social enterprises, they have no clear identity at the legal level, which results in its development process being subject to many restrictions. Initially, the GY was positioned as a private elderly care institution. Later, it cooperated with the government and became a public-private enterprise that was supported by the government. At present, it is positioned as an elderly care social enterprise. However, there are some controversies over elderly care social enterprises in both academic and practice fields, and the dual objectives of social enterprises  are like a double-edged sword because these enterprises are considered both a model innovation and a source of controversy. In short, social enterprises started late in China and are still in the exploratory stage. Many private nongovernment enterprises, institutions or organizations already have various elements or characteristics of social enterprises but do not have the “self-awareness” of social enterprises. Many social enterprises are torn between presenting themselves as general commercial enterprises or nonprofit organizations for the public good, and they do not have a clear understanding of their own function. “When I first came to GY, I thought it was a nonprofit social organization but later found that GY was in the development process, and except for government-related preferential policies, its development basically relies on its own profitability. However, there are a lot of elderly care institutions in society; no matter public, private or public-private construction, their identities are difficult to accurately position, so the positioning of GY is really difficult to say” (Interview record: 20201018).At present, the GY has achieved a certain degree of development; however, it still faces a shortage of external support in its development process, and these shortcomings have restricted its development to a certain extent. Through participant observation of the GY’s development process, the coding and analysis of relevant interview materials and observation notes and combining the external support analysis with the government-society-family framework, we found that the external support deficiencies affecting the sustainable development of elderly care social enterprises are reflected in main three levels: government, society and family.Government support was lacking during the start-up period of the GY. Analysis of the GY interview data revealed that this lack of government support can be understood in two ways.First, there was a lack of relevant policy support. The Ministry of Civil Affairs of the People’s Republic of China issued the Interim Measures for the Management of Social Welfare Institutions at the end of 1999, which was the only governmental policy document at that time, and this document addressed only the macrolevel aspects of liberalizing strict control over elderly care service providers and allowing social forces  to participate in elderly care services. Regarding what kinds of support the government would provide and what elderly care institutions should do, there is no clear leading document, and it is exceptionally difficult to create elderly care service institutions. The founder of the GY has strong feelings in this regard: “During the start-up period, the founders borrowed the start-up capital, rented an unused room, and ran around Nanjing’s old people’s homes, orphanages, and senior apartments to gain experience in elderly care services. It took nine months to go through the approval process. There was no support from the national policy system in this process” (Interview record: 20191018). Regarding the process of setting up the first elderly care service organization, a staff member from the management department said, “When your legs are an inch thinner, the elderly care service organization will be successful”. This means that the procedure to successfully register an elderly care social enterprise is very cumbersome, i.e., managers need to go to many departments in different regions or different functions to complete the necessary procedures (Interview record: 20191023). The procedure was extremely cumbersome and took nine months. The first elderly care service agency moved three times.Second, the policy system was difficult to implement because of poor coordination due to geographical and population divisions, the “one-size-fits-all” approach, and a lack of detailed provisions in land, finance, taxation, and other preferential policies, resulting in a lack of supporting policies for elderly care service institutions. In actual operations, it was also difficult to implement operating subsidies and caregiver subsidies for some elderly care institutions. The participants observed that the government had a preferential policy for elderly care service institutions in applying for discounted loans from The China Development Bank, but the bank does not provide such loans. Additionally, it was difficult to apply for certain funds allocated to elderly care institutions, such as the provincial pension industry fund jointly established by the Jiangsu Provincial Finance Department and Jinling Hotel Group. Therefore, insufficient financial support has limited GY’s pace of development to a certain extent (Interview record: 20191020).Along with the aging of the population in China, elderly care services have attracted increasing attention in all walks of life. The government has introduced a series of policies to realize the rational allocation of resources and meet the demand for elderly care services, and the GY has also entered the development chain period with the prevailing trend of government policies. However, during this period, the GY encountered serious divisions in the chain development process due to regional and population differences in support policies for elderly care. This division hindered the chain process and the sustainable development of elderly care social enterprises.First, in terms of construction subsidies, operational subsidies and care subsidies, there were differences among cities and regions, and some of these differences were quite large. Second, the gap between urban and rural areas of the same cities was also obvious. For example, in Suzhou, the per capita household pension for urban residents was 9534 yuan, while that for rural residents was only 4129 yuan . Figure Support organizations for social enterprises in the private sector recognize the importance of identifying them as social enterprises, but support for social enterprises remains weak.It was not until 2015 that the first civil social enterprise certification scheme emerged in China, namely, the China Charity Fair Social Enterprise Certification Scheme  issued by China Charity Fair Shenzhen. In 2015, only seven enterprises or social organizations in mainland China were recognized as social enterprises; the number increased to 16 in 2016 and 23 in 2017. In 2018, the Chengdu Social Enterprise Certification Center was established to create a comprehensive service platform for social enterprises in Chengdu, and in 2019, 46 enterprises and social organizations were certified as social enterprises in Beijing. As of January 2020, the number of social enterprises that had completed certification was 283. At present, few social organizations and enterprises have been certified as social enterprises, and more are considered quasi-social enterprises or potential social enterprises. Social enterprises have been operating in OECD (Organization for Economic Co-operation and Development) countries for almost 30 years, and as of 2015, there were 70,000 social enterprises in the UK (The United Kingdom of Great Britain and Northern Ireland), over 50,000 in Spain, and over 5000 in Scotland. Social enterprises have become the epitome of social innovation and the main force in the field of public welfare. At present, 22 countries have relatively complete social enterprise certification systems, and some European and North American countries have multiple certification models.Elderly care social enterprises can obtain government resources through government purchases of services and provide care services for elderly community members. For example, the GY provides free blood pressure and blood glucose measurements and related health consultation services for elderly individuals in the surrounding communities as well as meal purchasing services, rehabilitation services and nursing care services. However, in the process of chain location, the GY has encountered a serious “neighbor avoidance effect”; its locations have caused strong dissatisfaction among residents in surrounding communities who opposed the construction of elderly care institutions or senior service centers and opposed any form of day care or full care, creating many obstacles for the GY in its chain development process. Through detailed interviews, we found that residents of surrounding neighborhoods were worried that because elderly individuals are more prone to illness, more sick people would increase medical waste, which would not be conducive to the neighborhood environment. Additionally, elderly residents would be concentrated in one place, which would give neighbors an uncomfortable feeling of twilight and consume more public resources. Finally, with more elderly residents, there would be more funerals, which the neighbors did not want to see. On the other hand, in communities with more young residents, neighbors thought it would not be very meaningful to establish an elderly care community enterprise, and they believed it would reduce the quality of life and housing prices in the community. “If it is the government’s planning that requires the establishment of related senior care services to facilitate the needs of the elderly population, we have nothing to say about this kind of thing, but this kind of senior care social enterprise is for-profit, commercial, and occupies the public resources of the community, which directly affects the rights of other people in the community, which is unreasonable” (Interview record: 20191118). Therefore, the social acceptance of elderly care social enterprises in the community is not high. This situation is due to the late start of social enterprises in China and the lack of publicity to attract the attention and improve the understanding of the general public. On the other hand, elderly care social enterprises have failed to fully explore the strength of the community in the development process, resulting in insufficient community participation and lack of joint efforts to solve the problems of elderly care in the community. A community may have natural advantages in providing elderly care services, such as certain sites, human resources, community purchases of elderly care services, and active participation of community residents. Therefore, the GY did not fully mobilize the community and its residents’ motivation in the actual operational process, resulting in low social acceptance and insufficient community participation.Among elderly people, there is a certain prejudice against elderly care social enterprises, and they prefer to receive care from their children or professional medical services in hospitals rather than from elderly care social enterprises. Their children are afraid of appearing “unfilial” or fear that they will be stigmatized if they send elderly family members to elderly care social enterprises. Due to the traditional concept, some families have even experienced tragic accidents and deaths caused by a lack of caregivers and a lack of timely detection of health problems. Modern changes in the culture of filial piety have come, but the whole is still locked in the shackles of the tradition, and some old people will worry about their children being condemned by public opinion and do not want to accept the services provided by the elderly care social enterprises.In our study of the GY, we heard a story about Grandpa Lu from interviewee W7. Grandpa Lu, 73, who had worked as a surgeon in his youth, suffered from high blood pressure and diabetes for years and gradually showed signs of brain atrophy. He could not take care of himself and often left the house on his own. However, at that time, the decision of his two children to move him to a GY facility was controversial. Their mother was the first to disapprove, and her relatives, including her uncle, questioned why Grandpa Lu had been sent there. Colleagues, friends, and neighbors also regarded their behavior as unfilial. However, they worried that their father would get lost, that their mother would be dragged down one day, and that they would lose their father because they could not care for him properly. The public opinion of the outside world, their own ambivalence, and the criticism of colleagues led the two sisters to tears of sadness when recalling their experience (Interview record: 20191130).Some elderly individuals have limited ability to pay, and elderly care social enterprises must meet the demand by providing relevant services that require a certain expenditure. Although such costs are lower than those of for-profit elderly care institutions, they still require economic input from elderly residents and their families. According to the results of the survey, elderly individuals and their families have not formed a sense of consumption of elderly care services. Except for the home-based services supported by elderly care subsidies, families are less willing to purchase elderly care services at their own expense, and they are too dependent on the government. “If it is a free service, I will use it, but if I need to spend my own money to buy this, it still needs to be carefully considered, especially what spiritual comfort aspects, psychological aspects of these feel less useful, and their pension cannot pay” (Interview record: 20190930). The reasons for this limited ability to pay, from the perspective of development, include the relatively low level of economic development and the imperfect social security system. At the regional level, there is still a large gap between northern Jiangsu, with relatively low economic development, and southern Jiangsu, with high economic development, and the pension level in northern Jiangsu is generally low. Therefore, many elderly people with service needs cannot purchase elderly care services due to their limited ability to pay, which also hinders the sustainable development of elderly care social enterprises.Although the GY shows a good development trend at present, it is difficult for one or a few potential social enterprises to solve the social situation of insufficient demand for elderly care services in general. Moreover, as the previous analysis shows, the development process of the GY has been severely constrained by the lack of external support, which affects its sustainable development. This lack of external support restricts the creation and development of more social enterprises, resulting in a lack of self-awareness in many potential elderly care social enterprises, which makes already created social enterprises unsustainable or even ultimately causes them to disappear. Therefore, based on the in-depth analysis of the lack of external support for the GY, we constructed an external support system for elderly care social enterprises to create a friendly social environment in order to promote the sustainable development of such enterprises as an important main body of social welfare provision in China. The support of government, society, and family, as relevant stakeholders, has a positive contribution to elderly care social enterprises. This is consistent with the work of Phillips et al. .Government support is the top-level guarantee for the sustainable development of elderly care social enterprises and is reflected mainly in supportive and preferential policies, funding sources and recognition of legal status.First, the most important point from the perspective of supportive and preferential policies is reserving a place for elderly care social enterprises in the design of the social security system. According to the theory of welfare pluralism, the status and role of social enterprises in the provision of social services should be clarified, and a certain amount of funding should be provided for elderly care services. In terms of specific policy implementation, the government should consider the uneven development of elderly care social enterprises caused by population and geographical differences and pay attention to decentralization when formulating specific policies. Additionally, it should give full rights to the functions of local governments so that localities can introduce management policies to support the development of local elderly care social enterprises. For example, the government can implement the policy of “new homes with new methods and old homes with old methods” when issuing fire certificates for elderly care services, and new elderly care social enterprises should strictly follow the policy when applying for fire certificates. Established elderly care social enterprises or those converted in old neighborhoods should pass the fire department safety inspection to ensure that there are no safety hazards as the main criteria for renewing an establishment license. On the other hand, tax incentives and operating subsidies should be provided for social enterprises in terms of specific policies, and social enterprises should be prioritized in implementation, such as in the process of government purchases of services. The government can consider adding the social value factor when selecting procurement objects, examine the economic value-price ratio and social value-price ratio of different service providers, and select social enterprises that have price advantages and can attract good social value feedback. Based on the international development trend, in facing obstacles to the development of social enterprises, it is a trend for governments to promote the development of social enterprises through public policies . The supSecond, funding is a sufficient condition for the creation and sustainable operation of an organization. The public interest and welfare nature of elderly care services make elderly care social enterprises less profitable than general commercial enterprises, which leads to low interest in this industry among market capitalists and a lack of motivation to enter this industry, making it difficult for social enterprises to raise capital and find financing. This requires the government to help social enterprises in terms of funding; for example, the government can provide certain guarantees or assistance when social enterprises take out loans so that these enterprises can obtain lower loan interest rates than general commercial enterprises. Additionally, the government can establish social enterprise foundations and social enterprise start-up funds to provide financial support for entrepreneurs who are willing to create social enterprises. For example, the UK established the first Social Investment Bank in 2012 to provide more comprehensive financial services to social enterprises and established the Social Enterprise Incubator Fund to support social enterprises in their start-up phase. The government can also provide direct financial support to social enterprises to make it less expensive for social enterprises to obtain loans, set up a special loan fund for social enterprises that can be used to subsidize interest rates for small and medium-sized enterprises. The government can also encourage various foundations to set up social enterprise fund programs by providing tax incentives, opening “green channels” and so on. Many international organizations begin their support for social enterprises by providing financial support, such as loans and grants . HoweverAgain, in terms of legal status, the public in China has a high degree of recognition of the government, especially the central government. Although social enterprises have been certified by the private sector, at the government level, social enterprises still do not have their own legal identity, which has led to a certain degree of public skepticism toward social enterprises and low recognition of their social and economic value. It is imperative to legally recognize the status of social enterprises, yet the 2007 Korean Social Enterprise Promotion Act (SEPA) is the first and only social enterprise legislation in Asia. In addition to macrolevel policy and institutional support, government support for social enterprises strengthens the links among resources and clarifies the boundaries and scope of social enterprises. The legitimacy of social enterprises facilitates their access to more social resources .A friendly social environment is essential for the long-term development of elderly care social enterprises. There are many elements of a friendly social environment, and the emphasis here is on the support of organizations and community support. Organizations in various forms are important partners in the development of elderly care social enterprises. The community is a very special place in China. it is an autonomous organization, and it performs many administrative functions; thus, organizational support and community support play an important role in the development of elderly care social enterprises. The Social Impact Incubator is of great significance to the early development of social enterprises and the realization of their mixed goals . CommuniThe public welfare and microprofit nature of elderly care social enterprises require cooperation with related organizations, and the partners must have a certain sense of social responsibility and not focus on maximizing profits. In our case study, we found that the synergy of organizational support provided a constant impetus for elderly care social enterprises. For example, Golden Aging, the social enterprise that we interviewed, received support from its partners in the creation process. Four-fifths of the funds had come from friends, and the renovation company not only did not call for money for the renovation work but also advanced a certain amount of money that was not paid off until five years after the enterprise was founded. It is a good-hearted company with a sense of social responsibility that to a certain extent relieved the financial pressure at its beginning and provided help hand for its sustainable development. With the help of the Northeast Chamber of Commerce, the GY received the opportunity to participate in a three-person joint guarantee by the Postal Savings Bank and was eligible for a loan for two consecutive years; the Northeast Chamber of Commerce actively contacted various media to publicize and report on the GY to raise public awareness. Additionally, it invited relevant organizations in China and abroad to visit and guide the GY, thus increasing social awareness of the enterprise. The development of the GY also benefited from the support of certain organizations, such as companies that provide products for the elderly population, companies that provide food, and web-based information technology services.The community is the basic arena for aging in place, which many Chinese seniors are currently seeking to do, as they want to age in their own familiar community environment. Community support is the beginning of social enterprise service provision for elderly care. Elderly care social enterprises have a natural and close connection with the community. Judging from the development trend of elderly care, community care has become the common choice of different countries and regions, whether abroad or in China, and people prefer to receive elderly care services in their familiar living environment. As the main providers of elderly care services, social enterprises can meet people’s needs thus achieve their own sustainable development. The community can provide field support for elderly care social enterprises with the participation of community members, cultivate volunteerism, provide resources for less aged elderly people, and realize active aging. The community can provide venues, facilities, and even financial support. The participation of social enterprises in elderly care services is complementary to the realization of China’s home-based, community-based, and institution-based elderly care service system. For example, in the early stage, the GY set up a care institution for elderly people with disability and dementia as its main service object. In the process of chain development, it continued to cooperate with the community; actively respond to the actual needs of elderly people; take community elderly care as an important breakthrough point in the chain process; seek various kinds of community support; set up community elderly service centers, day care centers, elderly activity centers, and respite services; and increase the provision of medical care, rehabilitation aids, cultural, sports and entertainment activities, and clothing, food and catering services to create the necessary conditions for aging at home. The community is the main site of social participation. Social enterprises should fully utilize community resources and mobilize residents to participate, especially younger and unemployed elderly people, to provide social enterprises with volunteers and identify elderly people who may need care. At the same time, they can promote themselves in the community and improve public acceptance and recognition of social enterprises. Therefore, community support is a resource integration platform for social enterprises to participate in elderly care services. Through this platform, community acceptance and resource integration of elderly care social enterprises can be better realized to improve community participation.Family support is reflected mainly in changes in the family concept of aging, financial support, and spiritual comfort. Without the support of elderly individuals and their families, elderly care social enterprises are equivalent to water without a source and wood without a foundation. Therefore, in the process of social enterprise participation in elderly care services, the actual needs of elderly people and their families should be fully considered to obtain their support.Filial piety is a traditional cultural practice in China, but the specific forms of filial piety have changed considerably. Traditional forms of filial piety, such as “parents in, do not travel far”, “seeking carp on ice”, “burying children and serving mothers”, and “warming pillows”, have undergone great changes due to the large population flow, changes in forms of family cohabitation and finances, improvements in women’s family status, the decline of traditional patriarchal authority, and changes in intergenerational relations. The traditional concept of raising children to support parents in their old age has been challenged, the importance of daughters in supporting parents in their old age has been gradually recognized, social old age has entered people’s perceptions, and various forms of old age institutions are no longer avoided by elderly people and their families. In short, with changes in people’s concept of family aging, there will be a broader place for elderly care social enterprises.As China’s economic development continues to increase, per capita disposable income will continue to rise . The incThe sustainable development of elderly care social enterprises requires external support, i.e., exogenous guarantees, which is the main content of our research. On the other hand, elderly care social enterprises need to develop their own internal power sources, i.e., to develop their own advantages, including social entrepreneurship, innovative services and products, branding, chain business models, and advanced social enterprise concepts. Through the integration of “self-blooding” and “external blood transfusion” of social enterprises, the social support network of elderly care social enterprises can be built as a whole, and the social objectives and benign operations of social enterprises participating in elderly care services can be realized to achieve sustainable development. The terms “self-blooding” and “external blood transfusions” are widely used in many fields in China, such as the development of public welfare organizations, poverty alleviation and rural revitalization. The meaning of “self-blooding” means to focus on the internal motivation of things, i.e., through their own efforts to achieve development; “external blood transfusions” refer to external factors, i.e., the development of things through external support. In this process, “self-blooding” and “external blood transfusion” are indispensable, but our research focuses on external support for elderly care social enterprises and does not provide an in-depth analysis of the endogenous dynamics of elderly care social enterprises. Therefore, our study ignores the internal motivation of social enterprises to participate in the sustainable development of elderly care services. In addition, social enterprises, as social organizations, should be placed in a social ecosystem to comprehensively investigate their sustainable development. Only by specifically examining their interactions in the social ecosystem can we comprehensively study their sustainable development, which is the direction of the author’s future efforts.In addition, there are certain limitations in using a typical case study. One case can represent only one, or one type, of specific situation, and it is difficult to generalize the findings to the complexity and diversity of real elderly care social enterprises. In future research, we hope to supplement the shortcomings of one case study by using a multiple case study approach to include different types of elderly care social enterprises as much as possible.The GY as a potential elderly care social enterprise has achieved some sustainable development since its establishment in 1999. Firstly, it solves the care needs of some elderly individuals and continues to meet the care needs of elderly people in more areas through chain development. To some extent, it compensates for the deficiency of the government, the market, nonprofit organizations, and families in providing care services for elderly individuals and realizes the sustainable development of social value. Second, the GY has realized its own economic independence and sustainable development while realizing its social value. It depends on the preferential policy support of the government, but not entirely. Through the business operation mode and chain brand effect, personalized services are provided for elderly individuals with different needs, which leverages the consumption of care services by elderly people and their families and realizes the sustainable development of economic value.In the early days of the establishment of the GY, people’s assessment of the needs of elderly care services was unreasonable, and the preparation for dealing with population aging was insufficient. Although the government has relaxed the policy for elderly care service providers, especially for private elderly care service providers, there is no specific policy system for elderly care service providers at the highest level of the government. The GY‘s chain of development has been a period of intensive government support. They receive much support from policy to funding, from the central government to local governments. The government’s support for elderly care-oriented social enterprises is very important, and some studies have shown that these support policies have effectively promoted their prosperity and development. However, in the initial stage and development stage of these enterprises, due to the temporary and biased support, their effectiveness is insufficient. Therefore, in the process of policy support, it is necessary to evaluate and monitor the policy for a long time.Until now, the development of social enterprises in China has been very slow, and China has no clear official regulations regarding the identity of social enterprises. However, many potential social enterprises have been active in youth education, elderly service, disabled services, community development, rural poverty alleviation, public security and other fields, and they have achieved many positive results. The government gives a clear legal identity to elderly care social enterprises, which can improve public recognition of social enterprises and enhance their credibility. For example, the UK introduced the Public Services  Act in 2013, proposing that the government should examine both economic and social value factors when purchasing public services and prioritize purchasing services provided by social enterprises when other circumstances are equal. In Korea, the Social Enterprise Incubation Act requires the government to submit a plan for the purchase of social enterprise products and the number of purchases to the Ministry of Labor each year.Community plays an increasingly prominent role in the lives of the elderly population. When elderly individuals return from previously held jobs to the community, the community becomes the focus of their lives. Therefore, on-site elderly care has become the choice of many elderly people, which is also related to the actual needs of their families. Thus, elderly care social enterprises will engage in more sustainable development if they want to get full support from the community.The traditional concept of old-age care has a history of thousands of years in China. With the advancement of modernization, the traditional concept of old-age care has undergone new changes, but it is still deeply rooted in the overall culture. The family pension service is still the first choice for most people. This factor makes them hesitate to choose elderly care social enterprises.The change in the concept of family aging and the increase in family economic support for the elderly population does not mean a weakening of the family’s function in the aging process but rather a wider acceptance of the services provided by elderly care social enterprises. The enterprise itself should have the ability to meet the actual needs of elderly people; family members should make elderly people feel the warmth of their children while receiving these socialized services. In a country such as China, where filial piety culture is a long-standing tradition, the spiritual comfort of elderly people  is extremely important and cannot be provided or replicated by any elderly care social enterprise outside the family. Therefore, to achieve the continuous development of elderly care social enterprises, the provision of spiritual comfort to elderly individuals by family members is essential. While elderly individuals receive elderly care services provided by social enterprises, family members should take responsibility for spiritual comfort through regular visits by the younger generation, reunions on traditional holidays, and video calls using modern internet tools. Only through this two-pronged approach can elderly individuals feel the warmth of their families while receiving socialized elderly care services, which will improve their quality of life. Our research shows that government, society, and family play an important role in the development of social enterprises for elderly care.


For the last decades, endometriosis has been a major gynecological problem and a significant cause of infertility for women worldwide. It is estimated that the disease affects about 10–15% of all women of reproductive age and 70% of women suffering from chronic pelvic pain. At the same time, the incidence is about 40–60% in women with dysmenorrhea and 20–30% in women with subfertility. Despite the high percentage of affected women, endometriosis is still characterized by insufficient knowledge of the pathogenic processes, leading to the development and continuity of the disease. For this reason, there is a significant need for insight and understanding of the pathogenesis of endometriosis. This systematic review aims to present the latest data on the use of rats in endometriosis research and to explore how fertility is affected in rats with endometriosis. The methodology included a review of the available publications retrieved by a search in various scientific databases, such as PubMed, Scopus, Medline, and Google Scholar. The initial search generated 30 titles, with 10 articles fulfilling the inclusion criteria. In conclusion, several surgical techniques have been proposed to induce endometriosis, mainly using rats as the appropriate animal model. Studies in rats showed that endometriosis causes infertility and that pregnancy rates are lower for rats with endometriosis than those without endometriosis. In addition, rats with endometriosis have significant abnormalities in the structure of their oocytes as well as in the development of their embryos . Endometriosis has been a major cause of infertility and the most common cause of chronic pelvic pain for a significant number of women worldwide –8. EpideThe disease has a typical onset during early puberty, with an early age of menarche and acute pelvic pain that lasts during menstruation . Over the years, other symptoms result, according to the number of organs involved and the extent of the endometrial tissue covering them , 4. ThreDespite the high percentage of affected women, it is still characterized by insufficient knowledge of the pathogenic processes, leading to the development and continuity of the disease. For this reason, there is a significant need for knowledge and understanding of the pathogenesis of endometriosis. For ethical reasons, controlled experiments are not allowed in women with endometriosis. However, experiments are essential in animal models –7, 12–21The purpose of the current systematic review was to research how fertility is affected in rats with endometriosis.The methodology included a review of the available publications retrieved by a search in various scientific databases, including PubMed, Scopus, Medline, and Google Scholar. The most recent worldwide bibliographical references were studied, and the results were recorded chronologically (from the oldest to the most current ones). The research was based on inclusion criteria: (a) studies including rat models used to study endometriosis and subfertility; (b) full text available in English; and (c) period of publication between 1985 and 2020. The following search terms were used: "endometriosis", "rats", "subfertility", and "infertility", with the initial search generating 30 titles. Titles and abstracts were examined for relevance to the objective of the review. Following the assessment of the titles and abstracts, 20 publications were excluded as irrelevant to the study's objective. In the end, 10 articles remained for inclusion .The initial search generated 30 titles. Titles and abstracts were examined for relevance to the review objective. After assessing the titles and abstracts, 20 references were excluded because they were apparently not relevant to the study's objective. Finally, 10 articles were included in the review .Stating the bibliographical references in chronological order, in November 1985, Vernon & Wilson published a study about possible ways of surgical induction of endometriosis in rats . The artFive years later (May 1990), Rajkumar et al. published an article describing the effects of pregnancy and ovariectomy on the growth of endometrial implants in rats with experimentally induced endometriosis . ResultsIn December 1992, Barragán et al. published another study examining the effects of pregnancy and lactation on the ectopic endometrial tissue, as well as the fertility capacities, in rats that had experimental procedures to achieve endometriosis . The stuNext, in May 1995, Cummings & Metcalf published another study examining the role of environmental chemicals in the progression of endometriosis in rats . ExperimIn March 2002, Sharpe-Timms published another paper on how rats could be used as a research model to study endometriosis. The paper states that rats can be very useful for the deeper in vivo study of the pathogenesis and pathophysiology of endometriosis and in the study of novel therapeutic approaches that are not suitable to be tested in humans . FurtherIn November 2006, Mohammadzadeh et al. published another article on how endometriosis could be induced by implanting the endometrial fragments in rats. This article describes 2 groups of rats, (1) rats auto transplanted with endometrial tissues and (2) rats auto transplanted with fat tissue (control group), monitored after surgery (autotransplantation) for the clinical impact of the transplants and their development . The resIn April 2009, Stilley et al. published a study that examined the role of tissue inhibitors of metalloproteinase 1 in the reduced fecundity of rats with endometriosis. Even though the study does not present specific surgical techniques, it offers a significant explanation of how the expression of matrix metalloproteinases and their tissue inhibitors by ectopic and eutopic endometrium could play an important role in the pathogenesis of endometriosis . The resIn January 2012, Pelch et al. published a similar article about the use of rats as animal models for endometriosis, suggesting that some of the most important advantages of rats are the cost-effectiveness and availability (wide variety of transgenic mice) . The stuIn January 2015, Edson Ximenes Gomes Pereira et al. published a similar study about an animal model that could be used to understand the pathophysiology of endometriosis and the effects of certain pharmacological agents on endometriotic animals . The stuLastly, in February 2020, Dera-Szymanowska et al. published another interesting article suggesting that immunomodulation  seems to be able to inhibit the development of endometriosis at a substantially important level, thus moving one step forward from the implantation of the lesions, onto how these lesions could be reduced  in vivo .The probability of conception in women with mild endometriosis ranges between 2–5%, in contrast to 15–25% in healthy fertile women –36. The i.e., rats) [The first experiments on endometriosis were conducted on primates in the 1950s. In an attempt to simulate retrograde menstruation, the cervix of the female monkey was surgically repositioned in such a way as to cause endometrial lesions , 38. The., rats) , 38. Hum., rats) . Unlike ., rats) , 37, 38.., rats) . For theIn conclusion, according to all the studies above, it seems that endometriosis is a serious gynecological disease that can significantly reduce the patients' life due to both the acute, chronic pelvic pain and the subfertility issues it brings upon women of reproductive age. For these reasons, several surgical techniques have been proposed to induce endometriosis, mainly using rats as the appropriate animal model. There are many reasons why rats and rodents are used in these experiments. Firstly, due to the high reproducibility of the research, and secondly, due to low financial expenditure. The surgical techniques proposed include autotransplantation (transplants from the same rat to the same rat), and the results seem to be promising for the future, for the representation of the pathophysiology of the disorder, primarily in an animal model, and subsequently  in humans. Studies in rats showed that endometriosis causes infertility. Pregnancy rates are lower for rats with endometriosis (65.7%) than those without endometriosis (100%). Rats with endometriosis had significant abnormalities in the structure of their oocytes and the development of their embryos . Gene therapies and pharmacological agents play an important role when the appropriate therapeutic steps are taken, which results in a significant percentage of endometriomas being able to shrink substantially. In these ways, endometriosis can hopefully be well defined, studied, and clearly understood as a network of biological mechanisms in rats and humans, thus providing the scientific world with important information and contributing to the reduction in the rates of this disease in future years.


According to PAHO's annual 2022 Health in the Americas report, life expectancy fell by 2·9 years in Latin America and the Caribbean and by 1·8 years in North America. Major interruptions in essential health-care services reversed years of advances in prevention and treatment of communicable and non-communicable diseases, and vaccination programmes. Between 2021 and 2022, child vaccination coverage has fallen below 80% in nearly all South American countries, which are now at serious risk of measles and polio outbreaks.The Pan American Health Organization (PAHO) was created in December, 1902, in response to the yellow fever epidemic that killed more than 20 000 people in the Americas. Over its 120 years of existence, PAHO has evolved from a body that defines procedures and guidelines to hamper the spread of a disease, to one that occupies an essential role in supporting and advancing the entire regional health agenda. Over the past 3 years of the COVID-19 pandemic, the region of the Americas has been the hardest hit with agenda, the focus was on increasing genomic surveillance, strengthening human resources for health, and advancing universal health care. In her opening speech, PAHO's former director, Carissa Etienne reminded us that “disease knows no borders” and that we need to strengthen genomic surveillance and commit to collecting and sharing epidemiological data. In 2020, the COVID-19 Genomic Surveillance Regional Network (COVIGEN) was created to support the identification and tracking of new variants within the region, and now it could be extended to collect genomic data for the region—including data from the ongoing monkeypox outbreak—to support local health authorities and researchers. PAHO's outstanding record in supporting technical cooperation between countries and partnering with ministers of health, civil societies, and other international organisations speaks positively about how COVIGEN can grow into a reference tool to improve the region's emergency preparedness and help prevent future major outbreaks.At the 30th Pan American Sanitary Conference that took place in September 2022, health ministers and leaders from PAHO member states congregated to discuss the future of the region and elect PAHO's new director, who will lead the organisation for the next 5 years and undertake the daunting responsibility to guide the region through recovery. On the conference's overrepresented in lower-paying health-care jobs; thus, when reforming our health-care system, it is imperative to account for gender and race and ethnicity disparities within this sector. During the conference, PAHO and the U.S. Department of Health & Human Services presented a plan to improve the availability and quality of health workers in the region. Their initiative, the Joint Action to Strengthen the Health Workforce in the Region of the Americas, will facilitate the training of 500 000 health-care professionals in the next 5 years, expand PAHO's virtual campus, and create a consortium of academic centres in public health. The initiative is expected to facilitate a broader plan adopted by the member states in June 2022, at the IX Summit of the Americas: The Action Plan on Health and Resilience in the Americas. The action plan pledges to strengthen training and education, increase public financing for health, and to expand equitable access to quality health services. Disparities in access to health care and structural inequities within the region were exposed and exacerbated by the current COVID-19 pandemic, with systematically marginalised and vulnerable populations bearing the highest burden of the disease. A study done in Brazil, a country with the second highest absolute number of deaths globally, showed that universal access to primary health care mitigated inequalities in COVID-19 vaccination among the most vulnerable populations. Advancing universal health care and fighting for health for all should be a priority for the region, and PAHO's leadership will be essential for moving this agenda further, so that action points become achievements.The health-care workforce has suffered disproportionately during the COVID-19 pandemic, so recognising the need to expand and invest in the training of health-care staff is paramount. Pointed out by authorities and representatives in the audience of the conference, women make up 70% of health-care workers and Black women are Dr Jarbas Barbosa, who has inherited a fragmented region and a long list of challenges. Barbosa, the former assistant director, will lead the organisation through its mission to promote cooperation between countries to advance their health goals and improve the quality of the lives of the people of the Americas. At the same event, member states representatives and ministers of health from the region reaffirmed their commitments to meet the Sustainable Development Goals 2030 agenda. Getting back on track, and ensuring a sustainable recovery that leaves no one behind, will be a Herculean challenge for the Americas, and we will need everyone on board.As we recover once more from a devastating pandemic, PAHO is again to be a crucial part of our reconstruction plan. During the conference, PAHO elected its new director,