Alex Jingwei He

Health governance and healthcare reforms in China.

This article examines the role of health governance in shaping the outcomes of healthcare reforms in China. The analysis shows that the failure of reforms during the 1980s and 1990s was in part due to inadequate attention to key aspects in health governance, such as strategic interactions among government, providers and users, as well as incentive structures shaping their preferences and behaviour. Although more recent reforms seek to correct these flaws, they are insufficiently targeted at the fundamental governance problems that beset the sector. The article suggests that the Chinese government needs to heighten its efforts to enhance health governance and change the ways providers are paid if it is to succeed in achieving its goal of providing health care to all at affordable cost.

Explaining medical disputes in Chinese public hospitals: the doctor–patient relationship and its implications for health policy reforms

In recent years China has witnessed a surge in medical disputes, including many widely reported violent riots, attacks, and protests in hospitals. This is the result of a confluence of inappropriate incentives in the health system, the consequent distorted behaviors of physicians, mounting social distrust of the medical profession, and institutional failures of the legal framework. The detrimental effects of the damaged doctor-patient relationship have begun to emerge, calling for rigorous study and serious policy intervention. Using a sequential exploratory design, this article seeks to explain medical disputes in Chinese public hospitals with primary data collected from Shenzhen City. The analysis finds that medical disputes of various forms are disturbingly widespread and reveals that inappropriate internal incentives in hospitals and the heavy workload of physicians undermine the quality of clinical encounters, which easily triggers disputes. Empirically, a heavy workload is associated with a larger number of disputes. A greater number of disputes are associated with higher-level hospitals, which can afford larger financial settlements. The resolution of disputes via the legal channel appears to be unpopular. This article argues that restoring a healthy doctor-patient relationship is no less important than other institutional aspects of health care reform.

Fighting for Migrant Labor Rights in the World's Factory: legitimacy, resource constraints and strategies of grassroots migrant labor NGOs in South China

Chinas dizzying economic achievement is not mirrored in its labor rights protection record. Migrant workers in particular do not enjoy rights commensurate with their contribution to the economy. The pervasive infringement of labor rights and the failure of the official protective system have jointly created a niche for nongovernmental organizations (NGOs). This article investigates the grassroots migrant labor NGOs in the Pearl River Delta region, an area which has seen unprecedented increases in labor disputes both in terms of quantity and intensity. Making extensive use of in-depth interviews and participatory observations, it examines the strategies and tactics NGOs use for survival and growth in a hostile external environment. This article reveals that administrative illegitimacy and resource shortage have been the two key challenges for grassroots NGOs; in order to survive, they have developed a series of strategies to enhance legitimacy and explore resources. In the meantime, however, antagonistic thinking still drives the governments response to grassroots organizations unless the latter can skillfully balance political ideology and actual operation. Yet, overall, most NGOs still managed to survive despite various difficulties. Reciprocity and mutual trust are of critical importance to peaceful coexistence, if not cooperation, between the state and the grassroots. The building of long-term healthy labor relations in China necessitates more liberal thinking and collaborative governance.

An interim interdisciplinary evaluation of China’s national health care reform: emerging evidence and new perspectives

Five years have elapsed since the Chinese government unveiled its ambitious health care reform in 2009. A critical juncture in the reform process has been reached and it is time to assess its performance to date in order to inform the next phase of the reform. This article serves as both a review of important studies in the English language literature and the editorial of a special issue titled ‘An interim interdisciplinary evaluation of China’s national health care reform’. Comprising of six individual research articles, this issue represents a rigorous interim appraisal of the reform from an interdisciplinary perspective. The key message of this issue is threefold. First, social insurance is not the silver bullet for China’s health care reform; a revamp is needed to provide better financial protection and to facilitate the move to strategic purchasing. Second, orchestrated reform of the delivery system is needed to address the root causes of rapid cost escalation and vast inefficiency: provider payment reform is the key. Third, in managing the reform process, strategic attention must be given to the dynamic interaction of institutions and incentives. Good governance matters.

Towards Universal Health Coverage via Social Health Insurance in China: Systemic Fragmentation, Reform Imperatives, and Policy Alternatives

China’s remarkable progress in building a comprehensive social health insurance (SHI) system was swift and impressive. Yet the country’s decentralized and incremental approach towards universal coverage has created a fragmented SHI system under which a series of structural deficiencies have emerged with negative impacts. First, contingent on local conditions and financing capacity, benefit packages vary considerably across schemes, leading to systematic inequity. Second, the existence of multiple schemes, complicated by massive migration, has resulted in weak portability of SHI, creating further barriers to access. Third, many individuals are enrolled on multiple schemes, which causes inefficient use of government subsidies. Moral hazard and adverse selection are not effectively managed. The Chinese government announced its blueprint for integrating the urban and rural resident schemes in early 2016, paving the way for the ultimate consolidation of all SHI schemes and equal benefits for all. This article proposes three policy alternatives to inform the consolidation: (1) a single-pool system at the prefectural level with significant government subsidies, (2) a dual-pool system at the prefectural level with risk-equalization mechanisms, and (3) a household approach without merging existing pools. Vertical integration to the provincial level is unlikely to happen in the near future. Two caveats are raised to inform this transition towards universal health coverage.

Social protection in East Asian Chinese societies: challenges, responses and impacts

Being the world’s most vibrant economic engine, East Asia is facing daunting challenges in mitigating its social problems, including chronic poverty, vulnerability and worsening social inequality, despite its impressive economic growth. Governments in the region have increasingly recognized the need to improve the design and delivery of social protection to better target disadvantaged and marginalized groups. Innovations in social assistance, social insurance, and labour programmes are emerging, but both budget support and accountability mechanisms need to be strengthened (ADB 2013). Progress is being made in some quarters, but much remains to be done. The past decade has seen growing scholarly interest in the development of East Asian social policies not only because of the sheer size of the population and its global impact, but also due to the stark contrast between this region’s economic prosperity and the ongoing issue of severe social inequality (Cook and Kwon 2007, Asher and Kimura 2015). Growing disparities in East Asia in terms of income and wealth as well as unequal social opportunities reinforce each other, disproportionately affecting the vulnerable members of society, including the poor, youth, women, persons with disabilities, migrants and older people. Social policies can and must play a key role in ensuring that these groups are protected and are able to be included in the benefits associated with economic prosperity. The Chinese societies in East Asia – Mainland China, Taiwan and Hong Kong – offer an intriguing set of case studies to examine the changing socio-economic dynamics, their impact on the disadvantaged population and how various social protection programmes tackle poverty and vulnerability while fostering long-term inclusive economic growth. All of these societies belong to the so-called ‘East Asian cultural sphere’ that is heavily influenced by Confucian values, but to varying degrees. For example, while the social protection system in Mainland China manifests a mix of communist and market ideologies, the Hong Kong system has clearly inherited British colonial legacies. Partly determined by these ideological orientations, social protection systems in the Chinese societies also bear remarkably different characteristics (Walker and Wong 2005). In contrast to Mainland China and Hong Kong’s clear residualist stance towards social welfare provision, Taiwan is

Introducing voluntary private health insurance in a mixed medical economy: are Hong Kong citizens willing to subscribe?

BackgroundStruggling to correct the public-private imbalance in its health care system, the Hong Kong SAR Government seeks to introduce a government-regulated voluntary health insurance scheme, or VHIS, a distinctive financing instrument that combines the characteristics of private insurance with strong government regulation. This study examines citizens’ responses to the new scheme and their willingness to subscribe.MethodsFirst-hand data were collected from a telephone survey that randomly sampled 1793 Hong Kong adults from September 2014 to February 2015. Univariate and multivariate methods were employed in data analysis.ResultsMore than one third of the respondents explicitly stated intention of subscribing to the VHIS, a fairly high figure considering the scheme’s voluntary nature. Multivariate analysis revealed moderate evidence of adverse selection, defined as individuals’ opportunistic behaviors when making insurance purchasing decision based on their own assessment of risks or likelihood of making a claim.ConclusionThe excellent performance of Hong Kong’s public medical system has had two parallel impacts. On the one hand, high-risk residents, particularly the uninsured, do not face a pressing need to switch out of the overloaded public system despite its inadequacies; this, in turn, may reduce the impact of adverse selection that may lead to detrimental effects to the insurance market. On the other hand, high satisfaction reinforces the interests of those who have both the need for better services and the ability to pay for supplementary insurance. Furthermore, the high-risk population demonstrates a moderate interest in the insurance despite the availability of government subsidies. This may offset the intended effect of the reform to some extent.

Long-term care service needs and planning for the future: a study of middle-aged and older adults in Hong Kong

ABSTRACT Long-term care (LTC) planning is important in helping the older people tackle their future needs better. The needs for LTC services represent generational characteristics as they may be different between the current and upcoming cohorts of older adults. However, very few studies have examined the cohort differences in terms of their expected utilisation of LTC services, while understanding the patterns is crucial in helping policy makers prepare for the development of LTC services. This study fills the research gap by examining the plans and expectations for LTC services of 1,613 middle-aged and older persons in Hong Kong with data collected from a telephone survey. By applying the Andersen Model to examine LTC expectations, this study analyses the LTC needs and plans of the middle-aged and older cohorts of Hong Kong adults, as well as their associated factors, with a multiple logistic regression method. Both gender and birth cohort were examined individually and in combination. Birth cohort and gender have been found to exert an impact on all aspects of LTC needs and planning to varying degrees. The findings are interpreted and contrasted with those of a key study based in the West, with reference to the contextual characteristics of Hong Kong. This study furthers the scholarly understanding on LTC needs and planning and their cohort effect, and draws evidence-based recommendations for LTC development in Hong Kong, a rapidly ageing East Asian society.

Transplantation tourism in Asia: snapshot, consequences and the imperative for policy changes

The global shortage of transplantable human organs has been driving desperate patients mainly from the developed world to developing countries, looking for life-saving transplants. Asia is the major destination. Referred to as transplant tourism, this special flow of patients has been subject to vast controversies. However, the broad ethical condemnation and health concerns have largely failed to prevent this industry from flourishing. In contrast to the increasingly prosperous market, the existing regulatory frameworks are certainly ineffective. This chapter overviews the global picture of transplant tourism and particularly focuses on Asia. The situation in major destination countries, including India, Pakistan, the Philippines and China is outlined. This chapter also examines the drastic reforms adopted by Iran and Israel and articulates that while international coordination of organ transplantation policy is undoubtedly needed, the long-term resolution fundamentally lies in domestic efforts. It is imperative to move beyond ethical debates and embark on responsible and adaptive policy changes, with national self-sufficiency the ultimate goal.

Local Policy Entrepreneurship in Authoritarian China: The Case of a “Model” Health Care Reform

Over the past two or three decades, the concept of entrepreneurship has spread from the business realm into academic research, which has sought to explain public policy dynamics. Defined by Kingdon (1995) as individuals willing to invest their resources—time, energy, reputation and sometimes money—in return for future policies which they favour, policy entrepreneurs are thought to play a pivotal role in policy change and diffusion. In Kingdon’s multiple streams model, the policy process is conceived as policy windows which open as a result of the coupling of three streams—problems, policy content, and politics (Kingdon, 1995). It is argued that such windows could be joined by chance or by an entrepreneurial leader with a strong desire to effect significant change to current ways of doing things in his or her area of policy interest (Mintrom & Norman, 2009).