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Challenging the Economic Reform Paradigm: Policy and Politics in the Early 1980s' Collapse of the Rural Co-operative Medical System

Published online by Cambridge University Press:  01 April 2011

Jane Duckett
Jane Duckett
Affiliation:
University of Glasgow. Email: [email protected]
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Abstract

Over the last two decades an economic reform paradigm has dominated social security and health research: economic reform policies have defined its parameters, established its premises, generated its questions and even furnished its answers. This paradigm has been particularly influential in accounts of the early 1980s' collapse of China's rural co-operative medical system (CMS), which is depicted almost exclusively as the outcome of the post-Mao economic policies that decollectivized agriculture. This article draws primarily on government documents and newspaper reports from the late 1970s and early 1980s to argue that CMS collapse is better explained by a change in health policy. It shows that this policy change was in turn shaped both by post-Mao elite politics and by CMS institutions dating back to the late 1960s. The article concludes by discussing how an explanation of CMS collapse that is centred on health policy and politics reveals the limitations of the economic reform paradigm and contributes to a fuller understanding of the post-Mao period.

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Articles
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The China Quarterly , Volume 205 , March 2011 , pp. 80 - 95
Copyright
Copyright © The China Quarterly 2011

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References

1 I use the term “paradigm” here in the Kuhnian sense, as defining the parameters of enquiry and establishing its central premises and questions, but I do not claim, as Kuhn does for the natural sciences, that the economic reform paradigm encompasses scientific laws and particular research methods or techniques. See Kuhn, Thomas S., The Structure of Scientific Revolutions 3rd ed. (Chicago: University of Chicago Press, 1996 (1962))CrossRefGoogle Scholar.

2 The Third Plenum of the Chinese Communist Party's 11th Central Committee is conventionally taken as having initiated the economic reforms.

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7 Official policy has since at least 1992 taken the position that people who resist reform – whether officials or disgruntled workers for example – are simply conservatives who “need to change their thinking.”

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9 Although I have interviewed both national and local Chinese health researchers and officials, I have found none involved in late 1970s and early 1980s health reform initiatives (now 30 years ago) and able to comment authoritatively on them.

10 My analysis here has been influenced by other institutionalist work, notably that of Paul Pierson on policy feedback. See Pierson, Paul, Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment (Cambridge: Cambridge University Press, 1994)CrossRefGoogle Scholar.

11 My argument here is congruent with that of Linda Cook, who has shown bureaucratic stakeholders to be important to the fate of welfare and health in European authoritarian post-communist states. See Cook, Linda J., Postcommunist Welfare States: Reform Politics in Russia and Eastern Europe (Ithaca, NY: Cornell University Press, 2007)Google Scholar.

12 In contrast, urban health insurance protections were better defended because they had a credible funding source – enterprises – and therefore brought resources to the bureaucratic stakeholders (local labour and social security bureaus) in control of them. They were also untainted by Cultural Revolution associations, had been longer established, and provided access to better quality health care. See Jane Duckett, The Chinese State's Retreat from Health: Policy and the Politics of Retrenchment (London and New York: Routledge, 2011).

13 It did have antecedents in the 1940s CCP-controlled areas. See Han, Jun and Luo, Dan, Zhongguo nongcun weisheng diaocha (China Rural Health Survey) (Shanghai: Shanghai yuandong chubanshe, 2007)Google Scholar.

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16 Xinzhong Qian, Development and Decisions.

17 Feng et al., “Cooperative medical schemes”; Xuegai Kan, “Village health workers in China.”

18 Ministry of Health (ed.), Zhongguo weisheng nianjian 1983 (China Health Yearbook 1983) (Beijing: Renmin weisheng chubanshe, 1983), p. 206Google Scholar.

19 Lampton, The Politics of Medicine.

20 See e.g. “Fully accept the cooperative medical system welcomed by poor, lower and middle peasants,” Renmin ribao (People's Daily), 5 December 1968, p. 1.

21 It did not eliminate out-of-pocket payments. There are no reliable data for the 1970s, but data for 1980, when CMS was still relatively widespread, show patient fees to be 23% of total health spending. See Shaikh I. Hossain, “Tackling health transition in China” (Washington, DC: The World Bank, 1997).

22 Asian Development Bank, People's Republic of China: Toward Establishing and Rural Health Protection System (Manila: Asian Development Bank, 2002)Google Scholar.

23 Lampton, David, “The roots of interprovincial inequality in education and health services in China,” American Political Science Review, No. 73 (1979)CrossRefGoogle Scholar.

24 See e.g. “Huangcun, liangxiang gongshe dui leyuan gongshe shixing hezuo yiliao zhidu de yijian” (“The opinions of Huang village, Liang commune, on Leyuan commune's implementation of the cooperative medical system”), Renmin ribao, 5 December 1968, p. 1.

25 Xinzhong Qian, Development and Decisions. The total amount of rural collective health fund spending halved between 1982 and 1983, from just over two billion yuan to just over one billion. See Hossain, “Tackling health transition.”

26 It is not unusual to see estimates of around 90% of villages in China with CMS schemes in the 1970s, but David Lampton has shown pattern of CMS implementation to have varied enormously that decade. See Lampton, “The roots of interprovincial inequality,” pp. 459–77. CMS participation rates remained low after 1984 until a “new” rural CMS was promoted from 2005.

27 China Health Yearbook 1983.

28 Zhenpeng Xu and Bingguang Chen, “Jiaqiang hezuo yiliao caiwu guanli de changshi” (“Strengthen attempts to manage co-operative medicine financial affairs”), Renmin ribao, 17 February 1981.

29 Gu and Tang, “Reform of the Chinese health care financing system,” p. 186.

30 Blumenthal and Hsiao, “Privatization and its discontents,” p. 1167.

31 Jackson, Sukhan, Sleigh, Adrian C., Li, Peng and Liu, Xi-Li, “Health finance in rural Henan: low premium insurance compared to the out-of-pocket system,” The China Quarterly, No. 181 (2005), pp. 137–57 at p. 137CrossRefGoogle Scholar.

32 Wong, Victor C.W. and Chiu, Sammy W.S., “Health care reforms in the People's Republic of China: strategies and social implications,” Journal of Management in Medicine, Vol. 12, No. 4/5 (1998), pp. 270–86Google ScholarPubMed.

33 Gu and Tang, “Reform of the Chinese health care financing system,” p. 186.

34 Liu, Xingzhu and Cao, Huajie, “China's cooperative medical system: its historical transformations and the trend of development,” Journal of Public Health Policy, Vol. 13, No. 4 (1992), pp. 501–11 at p. 505Google ScholarPubMed.

35 According to Carl Riskin, the household responsibility system was in place in most parts of the country between mid-1982 and 1983. Riskin, Carl, China's Political Economy: The Quest for Development since 1949 (Oxford: Oxford University Press, 1987)Google Scholar.

36 Han and Luo, China Rural Health Survey.

37 I do not intend to imply here that the Ministry of Health was powerful within central government. Indeed the discussion below shows how it was constrained by the wider central government commitment to economic growth and decollectivization. However, the Ministry still did have considerable influence over health policies, particularly those that were congruent with the post-Mao modernization agenda and did not impinge on other ministries' interests.

38 “Yingming lingxiu Hua zhuxi zhichu: zhunque de wanzheng de guanche zhixing Mao zhuxi geming weisheng luxian” (“Wise leader Chairman Hua points out: accurately and completely carry out the implementation of Chairman Mao's revolutionary health line”), Renmin ribao, 20 August 1977.

39 Han and Luo, China Rural Health Survey.

40 See Xinzhong Qian, “Woguo weisheng shiye shengli fazhan de huigu” (“A retrospective on the victorious development of health work in our country”), in China Health Yearbook 1983.

41 Ministry of Health, Ministry of Agriculture, Ministry of Finance, State Administration for Medicine Management and the National Supply and Marketing Co-operative, “Nongcun hezuo yiliao gongcheng, shixing cao'an” (“Rural co-operative medicine constitution, draft programme for implementation”), issued on 15 December 1979.

42 Note, however, that the CMS constitution envisaged CMS developing along with the collective economy. Perhaps at this stage it was supported by pro-collective forces within the Ministry of Health against whom the tide was about to turn.

43 Xinzhong Qian, “Zai quanguo weishengjuzhang huiyi shang de jianghua (zhaiyao)” (“Speech at a national health bureau chief meeting (extract)”), 29 December 1979, in China Health Yearbook 1983.

44 Ibid. p. 33.

45 Xinzhong Qian, “Zai quanguo weisheng juzhang huiyi shang de zongjie jianghua (zhaiyao)” (“Concluding speech at a National Health Bureau Chief Meeting (extract)”), 5 January 1980, in China Health Yearbook 1983.

46 Bernstein, Thomas P. and Lü, Xiaobo, Taxation without Representation in Contemporary Rural China (Cambridge: Cambridge University Press, 2003)CrossRefGoogle Scholar.

47 “Weisheng gongzuo yao geng hao de wei sihua fuwu” (“Health work must better serve the four modernizations”), Renmin ribao, 7 March 1980.

48 Du, Haolin, “Nongcun hezuo yiliao zhidu de gaige” (“Rural co-operative medical system reform”), in Ministry of Health (ed.), Zhongguo weisheng nianjian 1984 (China Health Yearbook 1984) (Beijing: Renmin weisheng chubanshe, 1984)Google Scholar.

49 Xinzhong Qian, “Zai quanguo weisheng tingjuzhang huiyi shang de jianghua (zhaiyao)” (“Speech at a national meeting of health bureau chiefs (extract)”), 16 January 1981, in China Health Yearbook 1983.

50 Xinzhong Qian, “Guanche tiaozheng fangzhen, jiaqiang weisheng shiye jianshe” (“Grasp the adjustment line, strengthen the construction of health work”), concluding speech at a meeting of national health bureau chiefs, 24 January 1981, in China Health Yearbook 1983.

51 Qian himself has also since argued that CMS was allowed to “disintegrate” in part due to an “anti-‘leftist’ wave.” Xinzhong Qian, Development and Decisions, p. 96.

52 Xinzhong Qian, “Woguo weisheng shiye shengli fazhan de huigu” (“A retrospective on the victorious development of health work in our country”), in China Health Yearbook 1983, p. 14.

53 Xinzhong Qian, “Ba weisheng bumen de gongzuo zhongdian zhuanyi dao yiyao weisheng xiandaihua jianshe shang lai (zhaiyao)” (“Shift the emphasis in health department work to the construction of medicine and health modernisation (extract)”), in China Health Yearbook 1983.

54 There are few references to it until the end of the 1980s when it came back on to the policy agenda.

55 Haolin Du, “Rural co-operative medical system reform”; Haolin Du, “Nongcun zhong duozhong xingshi de yiliao zhidu” (“The multi-form medical system in the countryside”), in China Health Yearbook 1983.

56 Du reports that “In recent years … many localities have implemented medical contracts … and others have implemented a system of self medical self payment, that is [a system in which] the person going to the doctor pays the money.” Haolin Du, “The multi-form medical system,” p. 206.

57 Also noted by Feng et al., “Cooperative medical schemes.”

58 Reported by Xinzhong Qian, Development and Decisions.

59 Haidong Cao and Jianfeng Fu, “Zhongguo yigai 20 nian” (“20 years of health reform in China”), Nanfang zhoumo (Southern Weekend), 4 August 2005, at http://news.sina.com.cn/h/2005-08-04/10427410736.shtml, accessed 6 August 2007. This newspaper article was written during the publicity following a very critical report on China's health reforms published by the Development Research Centre in 2005.

60 Xinzhong Qian, “Shift the emphasis in health department work.”

61 See e.g. “The opinions of Huang village, Liang commune.” This article refers to doctors “losing their smell” when they go down to the countryside, a reference to the Cultural Revolution classification of intellectuals as the “stinking ninth category” inferior to the peasant and worker classes.

62 Stuart R. Schram, “'Economics in command?' Ideology and policy since the Third Plenum, 1978–84,” The China Quarterly, No. 99 (1984), pp. 417–61.

63 Xinzhong Qian, Development and Decisions, p. 102. This book was written by the 1979–82 Minister of Health.

64 “Resolution on certain questions in the history of our Party since the founding of the People's Republic of China,” adopted by the Sixth Plenum of the 11th Central Committee on 27 June 1981.

65 Small-scale private practices across the country had been severely criticized as capitalist during the Cultural Revolution and 44,000 of them were eradicated. See Ministry of Health, “Weisheng bu guanyu yunxu geti kaiye xingyi wenti de qingshi baogao” (“Ministry of Health report asking for instructions concerning the question of permission for individual health practices”), 20 August 1980, in Ministry of Health Office (ed.), Zhonghua renmin gongheguo weisheng fagui huibian 1978 nian–1980 nian (Collected Health Laws and Regulations of the People's Republic of China, 1978–1980) (Beijing: Falü chubanshe, 1982)Google Scholar.

66 In its report asking for permission, however, the Ministry's arguments for CMS were ones that would appeal to top leaders: private practice was already emerging spontaneously and that permitting it would enable it to be managed; it would provide work for unemployed medical practitioners; it would make visiting a doctor more convenient for “the masses”; and it would “serve the four modernizations.” Ibid.

67 Argued by Qian Xinzhong. See Development and Decisions.

68 Xinzhong Qian, “Wo guo weisheng shiye shengli fazhan de huigu” (“A retrospective on the victorious development of our national health work”), in China Health Yearbook 1983. Qian cited the guarantee in his 16 January 1981 speech, but did not mention it in his anti-leftist speech on 24 January 1981 and it does not appear in Ministry documents thereafter.

69 Xinzhong Qian, Development and Decisions; Haolin Du, “Dadui (cun) weisheng jigou de gaige” (“Brigade (village) health service provider reform”), in China Health Yearbook 1984.

70 Xinzhong Qian, Development and Decisions.

71 Qian reports that although there had also been good examples of good practice, CMS was abandoned in the rush to private practice. See ibid.

72 “Health modernization” is the focus of the Minister's annual work report in March 1979, where it is seen as the key to all health work. See Xinzhong Qian, “Shift the emphasis in health department work.” Here, the health sector's “concrete tasks for 1979,” which are conventionally in order of priority, were set out as: reorganizing the management of health service providers; strengthening medical science research; strengthening medical education; continuing to focus on prevention; combining traditional and western medicine; pharmaceuticals management; birth control; and foreign affairs.

73 Lampton, The Politics of Medicine in China. Barefoot doctors' incomes began to decline relative to those of farmers as agricultural incomes rose. Note that the Ministry of Health did argue that barefoot doctors' wages should be increased. See State Council, “Guanyu nongcun geti gongshangye de ruogan guiding” (“Some regulations concerning rural individual industrial and commercial business”), 27 February, 1984.

74 Lampton, The Politics of Medicine in China, pp. 241–42.

75 Bernstein and Lü, Taxation without Representation. I have found no accounts of protests in defence of CMS.

76 Changlu Huang, “Chijiao yisheng xuyao tigao: canjia Qinghaisheng weisheng gongzuo huiyide ganbu he chijiao yisheng lianxi shiji, pipan ‘Sirenbang' fandui, pohuai chijiao yisheng tigao yiliao jishu de fangeming zuixing” (“Barefoot doctors must improve: cadres and barefoot doctors participating in Qinghai provincial health work meeting connect with reality and criticize the ‘Gang of Four's' counterrevolutionary crime of opposing and damaging barefoot doctor improvement and medical technology”), Renmin ribao, 9 June 1978. See also Xuegai Kan, “Village health workers in China.”

77 Jingcun Yang, Yongnian Jiao and Aihong Wang. “Ni chou ta chou sheyuan fachou” (“You gather, he gathers, commune members worry”), Renmin ribao, 8 December 1979.

78 Xinzhong Qian, “Concluding speech,” 5 January 1980.

79 The 5% of villages that retained CMS are likely to have had schemes that worked reasonably well. They may have been localities where rural industry brought in collective revenues that allowed CMS to be relatively generously funded, or where local officials and their superiors were promoted in the Cultural Revolution and prepared to risk retaining schemes.

80 Cao and Fu, “20 years of health reform.” These authors argue that the Ministry took a lead in the reforms with health policy initiatives to introduce material incentives.

81 “Guanyu quanguo gongshang xingzheng guanlijuzhang huiyi de baogao” (“Report concerning a national meeting of industrial and commercial administration bureau chiefs”), approved by the State Council. The meeting was held in February 1979 and approval was reportedly given soon after. See “Guojia gongzhangzongju juzhang Zhou Bohua tan gongshang xingzheng guanli jiguan 30 nian de gaige fazhan” (“State administration for industry and commerce bureau chief Zhou Bohua discusses 30 years of industrial and commercial administration department reform and development”), Xinhua, 24 September 2008.

82 State Council, “Guanyu chengzhen feinongye geti jingji ruogan zhengcexing guiding” (“Some policy-type regulations concerning urban and town non-agricultural individual economy”), 7 July 1981; National People's Congress, The Constitution of the People's Republic of China (Beijing: Foreign Languages Press, 1982)Google Scholar; State Council, “Some regulations concerning rural individual industrial and commercial business.”

83 Susan Shirk and others have shown economic reforms to have had political motivations but not more right wing ideological ones. See Shirk, Susan, The Political Logic of Economic Reform in China (Berkeley: University of California Press, 1993)Google Scholar.

84 Even if CMS had not been as successful as it is often portrayed, and did not in the 1970s guarantee access to health services, there had been a commitment to expanding and improving it.

85 Minister Qian himself has noted this in relation to health policy in the early 1980s: “the socialist direction in health work was not clear enough” (shehui zhuyi ban yi fangxiang bu gou mingque). Xinzhong Qian, Development and Decisions, p. 96.

86 The classic definition of the subject of politics as set out in Lasswell, Harold D., Politics: Who Gets What, When and How (Gloucester, MA: Peter Smith (1950 ed), 1935)Google Scholar.