Acting reactively: private investment, controversies and regulatory and policy responses in residential long-term care in Ontario (Canada), Lombardy (Italy), the Netherlands and England (United Kingdom)

Private investment in residential long-term care has surged around the world. Growing evidence shows that this is changing the institutional logic and the inner workings of the sector, prioritising the financial interests of asset holders above those of other stakeholders (eg. clients, care professionals and regulators). We know little about how policy makers and regulators are responding to private investment and profit-making in the long-term care sector. This paper addresses that gap by analysing policies prompting the growth of private investment and profit-making in residential long-term care, the emerging power struggles in some cases between asset holders and other stakeholders in long-term care, the controversies that have arisen and the concomitant responses of regulators and policy makers in Ontario (Canada), Lombardy (Italy), the Netherlands and England (United Kingdom). We show that the institutional context (eg. legal frameworks, policies and regulations) shapes controversies concerning quality, accessibility and affordability of care, and argue that regulators and policymakers in the constituencies we studied are responding reactively to such controversies rather than proactively anticipating and preventing unwanted effects. Our analysis provides policymakers with valuable insights regarding the regulation and governance of private investment and profit-making in the residential long-term care sector.