Technocratic capacity and policy change: shaping the universalisation of healthcare in China

In the first decade of the twenty-first century, the expansion of Social Healthcare Insurance coverage and public health service provision in China were compromised by regional policy fragmentation and correlated discrimination against the domestic migrant population, who moved across geographic areas. Nevertheless, how has the Chinese healthcare reform developed a new trend over the last decade, which has emphasised expanding effective Social Health Insurance coverage and equalised basic public health services to migrants, thus taking a crucial step towards Universal Healthcare Coverage? This trend is buttressed by a more unified and coordinated system that is amiable to benefit portability and wider healthcare access. Nevertheless, the received wisdom does not provide an effective explanation for such a trend. The literature shows that due to the hefty amount of autonomy enjoyed by local leaders who seek revenue-based or promotional opportunities through intense competitions with counterparts in other regions, localism is likely to persist. These local leaders have gained power from national leaders through top-down political delegation. While such a “principal-agent” framework facilitates the understanding of the complex policymaking and implementational processes within China’s multi-level governance structure, it does not show how the country overcomes some substantial institutional barriers and makes progress towards Universal Healthcare Coverage, albeit having not achieved full universalism. This thesis offers an explanation by bringing technocrats back in. I developed a nuanced “principal-agent” model, which considers the autonomy and policy impact of the technocratic community. This thesis argues that technocratic interests and actions generate an important counterbalancing impact on the policymaking tendency to fragmentation and localism, which is inherent in the incentive mechanism concerning leaders. Ministerial technocrats utilise the “promotion tournament 2.0” mechanism as an institutional guarantee to rein in local officials, while also mobilising subordinates on the basis of esprit de corps. With a collection of empirical papers, this thesis takes a mixed-methods approach to address academic debates situated at the intersection of Chinese politics, public administration and social policy disciplines.