Too little, but not too late? Health reform in rural China and the limits of experimentalism

Abstract

This article provides a preliminary evaluation of health care reforms in rural China, with particular focus on villagers’ perceptions of the quality of care and the rural health insurance programme. Based on semi-structured interviews and an original survey of villagers in three provinces, this study suggests that, although recent reforms may have somewhat reduced the out-of-pocket cost of catastrophic illness, rural health systems continue to suffer from serious deficiencies. By examining villagers’ perceptions of health care, this article argues that initial conditions and incentive structures interact with local policy styles to impede effective health care reform in rural China.

Keywords:

• China
• health care
• rural politics
• decentralization

Acknowledgements

The author thanks Melanie Manion, Edward Friedman, Christina Ewig and the participants in the Chinese Politics Workshop at the University of Wisconsin–Madison for their comments throughout this research project.

Notes

1. This phenomenon has been described as ‘rule by law,’ in contrast to the ‘rule of law’ in democratic systems (Lubman 1999; for a discussion of ‘rule by law’ in authoritarian regimes beyond China, see Ginsburg and Moustafa 2008).

2. All translations from Chinese are my own.

3. In 2013, the Ministry of Health merged with the National Population and Family Planning Commission and the State Administration of Traditional Chinese Medicine to form the National Health and Family Planning Commission.

4. Since this research was conducted, there have been central government initiatives to standardize some aspects of the NCMS, but the primary grievances of villagers as described in this research persist.

5. Jiangsu is the wealthiest, Hubei is middle-income and Yunnan is the poorest and most agrarian in the sample. As a measure of wealth, we used the most recent statistics available for the municipality’s gross regional product per capita; these are published by the provincial government in statistical yearbooks. Jiangsu is located in the littoral region, while Hubei is in central China, and Yunnan is in south-western China (see Figure 1). Jiangsu and Hubei do not have significant populations of ethnic minorities, whereas Yunnan has a large, but varied, ethnic minority population.

6. Publicly available lists of counties and townships were reliable, but additional information that would have been required for a stratified sample of villages was not reliably and consistently available in all provinces. Therefore, we elected to select counties, townships and villages within each municipality randomly.

7. Municipalities, also sometimes translated as prefectures or prefecture cities (dijishi), constitute an administrative unit one level below the province that is relatively large. Each province in the sample has between 13 and 16 municipalities.

8. For additional information about the data collection process, please contact the author.

9. Of course, selecting favourable conditions for pilot projects is probably not a wise approach to testing the viability of a new policy, but this issue is beyond the scope of this article.

10. For one explanation of why wealthier provinces are afforded greater autonomy, see Sheng (2010).

11. Typically, nine years of compulsory education, beginning at age six, are virtually free in public schools. Public secondary schools, however, increasingly charge various operating fees that can be a significant burden on lower income families.

12. The county has received some media coverage from the state media for its efforts (‘Public welfare programs in Shenmu County, Shaanxi Province,’ 2009).

13. Official estimates placed the Gini coefficient at around 0.47 in 2012 (Yao and Wang 2013), but others speculate that it could be much higher.

14. The current practice of medicine suffers from generations of Chinese physicians whose professional careers have been contingent on demonstrating loyalty to the state and communist ideology, in lieu of professional ethics (Lim et al. 2004). For more on the need for the professionalization of physicians, see Cao (2011).

Additional information

Funding

The author gratefully acknowledges research support provided by the National Science Foundation Doctoral Dissertation Improvement Grant programme, the Foreign Language and Area Studies Programme of the US Department of Education, the Department of Political Science of the University of Wisconsin–Madison, and writing support from the Chiang Ching-kuo Foundation.