2012年-世界发展银行全球_Chinese-Style_Decentralization_and_Health_System_Reform_4页_169kb

Chinese-Style Decentralization and Health System Reform Summary

Core Content

China's health system reform (HSR) has entered its second phase, with a focus on achieving universal access to basic health services by 2020. The reform is structured around five pillars, including expanding health insurance coverage, reforming drug pricing, improving primary health care, strengthening public health services, and reforming public hospitals. Despite notable achievements in insurance coverage and infrastructure development, challenges persist in service quality, financial risk for individuals, and tracking health outcomes.

Main Viewpoints

• Equity and Access: Access to health services is improving, but the equity objective remains challenging due to the decentralized nature of China's governance and limited local government accountability.
• Decentralization Challenges: The health sector is subject to a complex system of decentralized responsibility, with local governments primarily driven by economic development rather than social welfare.
• Funding and Governance: While national funding for HSR has increased, the majority of sectoral funding and implementation are managed at the sub-national level. This has led to inconsistencies in progress and limited oversight.
• Incentives and Accountability: Local governments often view health as a cost rather than an investment. There is a lack of clear incentives for them to prioritize health reforms, despite national directives.
• Information Systems: A new health management information system (HMIS) is being introduced to improve oversight, but it lacks independent tracking of health outcomes and may not fully address data gaps.

Key Information

Five Pillars of HSR

1. Expanding Subsidised Health Insurance Coverage: Increasing insurance benefits and unifying schemes.
2. Drug Reform: Zero mark-up on essential medicines.
3. Primary Health Care Improvement: Enhancing access and quality.
4. Community-Level Public Health Services: Screening and management for all.
5. Public Hospital Reform: Restructuring hospitals to focus on public good rather than profit.

Decentralization and Governance

• Federalism Structure: China's federalism involves hierarchical delegation, financial transfers, and vertical competition.
• Local Government Priorities: Local governments are mainly focused on economic growth, not social development.
• Funding Allocation: Central government funds only a portion of HSR initiatives, with local governments expected to contribute significantly.

Performance and Monitoring

• Performance-Based Management: Initiatives like the HMIS and performance evaluation systems are being introduced to improve oversight and accountability.
• Accountability Gaps: Local authorities are accountable to higher levels, not the public, and there is limited independent monitoring of health outcomes.

Challenges and Recommendations

• Weak Incentives: Local governments lack strong incentives to prioritize health, especially in poorer regions.
• Data Gaps: There is a lack of independent, population-based health outcome data, which hinders the assessment of HSR impact.
• Need for Parallel Reforms: Reforms in governance, financing, and accountability are necessary to ensure equity and effectiveness in the health sector.

Conclusion

HSR in China has the potential to improve health equity by standardizing care and public health services. However, success depends on sub-national governments being more accountable and on strengthening vertical monitoring of health service quality and outcomes. These reforms require coordination beyond the Ministry of Health and align with national priorities and the state's increasing focus on local government performance in public welfare.

Author Contributions

• Data Analysis: David Hipgrave, Sufang Guo, Yan Mu, Yan Guo, Fei Yan, Robert Scherpbier, Hana Brixi
• Manuscript Writing: David Hipgrave
• Contributions to Writing: All authors
• Authorship Criteria: All authors met the ICMJE criteria

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