Strong state, weak system: social health insurance in rural China 1956-2007

Thesis

A question of great interest to China watchers is whether or not central mandates are successfully implemented, and how. The issues surrounding this question are at the heart of the analysis in this thesis about China's attempts to institute social health insurance schemes in rural areas from 1949 to 2007.

The thesis looks at central government attempts to institute social health insurance schemes between 1949 and 2007 and tries to explain the significant variation in enrolment in social health insurance across this experience.

The study shows that implementation of social health insurance schemes in rural China, measured in terms of their widespread uptake, succeeded on two occasions. There also have been a number of failures and collapses of social health insurance schemes in rural China.

To explain the variation, the thesis first constructs a framework of how rank and authority of decrees work in the Chinese Communist Party. This framework allows an evaluation of how implementation decrees are transmitted down from the centre to local areas (who implement policy).

The thesis argues that the issuing of a central decree holding the local Party secretary to account for high enrolment is the necessary and sufficient condition for the central government to ensure high enrolment in social health insurance schemes. The issuing of a central decree is shown only to be a necessary condition, but not a sufficient condition. And the holding of the local Party secretary to account must occur through the Party governance system rather than through the health governance system.

The thesis shows that the rise, fall, failure to rise, and then unexpected rise of social health insurance can be explained by the systems of coordination and control used to hold the local Party secretary responsible for ensuring high levels of enrolment in health insurance. It shows that only the local Party secretary can mobilise the local state sufficiently to meet central decree. And only certain central decrees can motivate the local Party secretary sufficiently to mobilise the local state.

The thesis concludes by applying this framework to broader questions of health system reform in modern-day China. It draws tentative conclusions as to how wider health system reform can be understood through the thesis' analytical framework and suggests testing this framework in other policy contexts.

Authors: Manuel, R

• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford