RESEARCH ARTICLE

Deliberative Democracy Nationwide?—EvaluatingDeliberativeness of Healthcare Reform in China

Alexander Korolev

Published online: 4 April 2014# Journal of Chinese Political Science/Association of Chinese Political Studies 2014

Abstract To date, China’s deliberative institutions have mainly been seen as small-scalemechanisms for controlling local social unrest. This paper explores how deliberativeprinciples in China work at the national level. The case under scrutiny is China’s newhealthcare reform. Drawing on the existing empirical studies, Chinese-language reports andarticles, official document analysis, and on several unstructured interviews with Chineseacademics, the article attempts to evaluate the extent to which deliberative democraticprinciples are present in the process of healthcare policy making. To achieve this analyticalgoal, it develops and applies five criteria of good deliberation. The analysis suggests that thepublic policy process in China is now more inclusive and pluralistic than it was in the past.This arguably indicates that China’s political system is moving in a new direction.

Keywords Deliberative Democracy . Public Policy . Participation . Healthcare Reform .

China

Introduction: Deliberative Approaches and China’s Healthcare Reform

A significant aspect of the “deliberative turn” in democratic theory resides in the factthat it has pointed to new avenues of democratization that bypass the implementation of

J OF CHIN POLIT SCI (2014) 19:151–172DOI 10.1007/s11366-014-9287-1

A. KorolevNational Research University Higher School of Economics, 20 Myasnitskaya Ulitsa,Moscow 101000, Russiae-mail: a.korolev@hse.ru

A. Korolev (*)Center on Asia and Globalization, Lee Kuan Yew School of Public Policy, National University ofSingapore, 469 C Bukit Timah Road, Singapore 259772, Singaporee-mail: akorolev@nus.edu.sg

competitive elections. Despite proponents of ideal deliberative procedures questioningthe possibility of true deliberation to exist in a country where top leaders are notelected, [1–3] advocates of broader applicability of deliberative approaches argue thatany particular set of institutions, including competitive elections, is not a necessaryprecondition for effective deliberation. What a political system needs in order todemonstrate deliberative capacity is a structure capable of hosting deliberationthat is authentic, inclusive, and consequential. Deliberative principles can,therefore, apply in all kinds of political settings, be it authoritarian regimes,new and old democratic states, or even governance structures that elude states[4, 5].

In this light, deliberative approaches to policy making have gained wide currencyamong Chinese politicians as well as in academic debates over China’s politicaltransformation. The Chinese government actively encouraged the development ofdeliberative institutions and financed countless deliberative exercises across the coun-try. Numerous deliberative forums, such as Citizen Evaluation Meetings, The Residen-tial of Village Representative Assemblies, or The Consultative and Deliberative Meet-ings, took place in many cities, villages and counties in China. Against the backdrop ofproliferating deliberative practices, some scholars have announced a “deliberative turnin Chinese political development” [6]. They emphasize that deliberation is notnecessarily reserved for liberal democracies and reject the assumption thatChina cannot develop deliberative democracy without establishing a nationwideelectoral system. It is argued that despite the state playing a central role indeveloping, mobilizing and promoting deliberative institutions, deliberation doestake place in China [7]. “Deliberative democracy” (xieshang minzhu 协商民主)has become one of the “hot” political science topics domestically in China aswell [8, 9].

While being popular, academic debate on deliberation in China seems to have somefeatures that may limit further discussion of the probable “deliberative democratization”of China. To date, deliberation in China has been seen as local in scale. Deliberativepractices have mainly been described as small-scale mechanisms of regulating localsocial unrest and as playing the role of a “valve” to release the pressure caused by rapideconomic transformation [10]. The main purpose of practicing deliberation was tomaintain local order, provide policy consultation at the local level, legitimize localpolicy making, and to mollify the public when anger spills out in numerous localprotests [11–13]. In most cases, under scrutiny are local community-based problemssuch as, for instance, the price of water or electricity, local park entry fees, therelocation of farmers in a certain county, the issue of the conservation of historicallandmarks, the Beijing Zoo issue1 and the like. It has been observed by deliberativedemocracy theorists that

if China had any deliberative capacity, then it could be found only in participatoryinnovations at the local level, designed in part to cope with the unwanted sideeffects of rapid economic growth, but if to focus on central state institutions andthe public sphere, then China thoroughly lacked deliberative capacity.2

1 He, “Participatory and Deliberative Institutions in China,” 175.2 Dryzek, “Democratization as Deliberative Capacity Building,” 1383.

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In this respect, “The New Healthcare Reform” (xin yiliao gaige 新医疗改革, NHRhereafter), aimed at establishing a universal health-insurance system in China, providesa unique case study. The introduction of a universal health-insurance system is anational-level endeavor that involves the interests of various stakeholder groups. TheNHR has been characterized by a very inclusive public discussion involving the generalpopulation, domestic and international think tanks, and various interest groups. Differ-ent channels of interaction and transmission of information among different playershave been constructed. Soliciting comments from the public; many commissionedstudies, including ones by WHO and the World Bank; heated internal debates amongvarious ministries and diverse vested groups; active use of the internet; discussion ofthe reform drafts by the then Premier Wen Jiabao with different stakeholders—all havebecome characteristics of the New Healthcare Reform. Inviting the public to participatein the public policy process is unprecedented in China. In light of the scope and rangeof public involvement, some scholars called the whole process “healthcare democracy,”done both “for the people” and “by the people” [14]. This makes NHR a significantcase for understanding how deliberative principles work at the national level in China.

This paper draws on the existing empirical studies, official document analyses, andseveral unstructured interviews with Chinese academics to evaluate the deliberativenessof “healthcare deliberation” in China. Section 2 develops and operationalizes ananalytical framework that allows us to apply deliberative approaches to explorenationwide policy-making processes in the context of the Chinese political regime.Section 3 applies this framework to China’s NHR episode lasting from July 2005—when the Chinese government officially acknowledged the failure of its health policiesand committed itself to new reforms—to March 2009—when the final draft of thereform was adopted. The main interest is in the “deliberativeness” of the public policyprocess during this period. Section 4 concludes. The basic thesis statement of the paperis that effective deliberation in China takes place not only locally, but also on thenational level.

Criteria of Good Deliberation and NHR—An Analytical Framework

Different interpretations of deliberative democracy tend to converge on some basicfeatures constituting good deliberation. A synthesizing definition is provided by dellaPorta, who suggests that “we have deliberative democracy when, under conditions ofequality, inclusiveness and transparency, a communicative process based on reason (thestrength of the good argument) is able to transform individual preferences and reachdecisions oriented to the public good” [15].

The first quality good deliberation must possess is thus inclusiveness of the delib-erative spaces, 3 expressed in the diversity of participants with different perspectives,but facing common problems. Inclusiveness requires the bringing together of people

3 Dryzek distinguishes two deliberative spaces: public space—a deliberative space that can be found in themedia, social movements or other public gatherings, which has no restrictions on who can participate; andempowered space—a deliberative space for policy makers. Both public and empowered spaces can be subjectto tests for the degree to which they are inclusive of relevant interests and voices. See Dryzek, “Democrati-zation as Deliberative Capacity Building.”

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with very different viewpoints on the issue under deliberation. 4 It implies engagementof both the experienced and the marginalized groups in policy discourses [16]. Everypoint of view needs to be included, even though not all in a community are given anequal opportunity to deliberate [17]. An ideal deliberative process takes place when allstakeholders are included in the decision-making process and are able to express theirpreferences. 5 Empirically, inclusiveness can be operationalized in terms of “whodeliberates.” In our case of the healthcare deliberation in China, the key empiricalquestions, therefore, are: were holders of different views allowed to participate in theprocess of deliberation? Were different groups, affected by the healthcare reform, ableto articulate their demands? Were deliberative spaces—media, the internet, or publichearings—open for participation and capable of networking associations, experts, andindividuals of various backgrounds?

The second criterion of good deliberation is equality or equal participation. “For theprocess of deliberation…to work as it should, participants need to be on equal footing”.6 According to Cohen, deliberative democracy requires some forms of equality amongcitizens. 7 Good deliberation happens when “no one person or advantaged groupcompletely dominates the reason-giving process, even if the deliberators are not strictlyequal in power and prestige” [18]. In empirical terms, a decision-making process can becalled relatively equal when different interests have a fair share of access to thedeliberation floors, such as forums, conferences or public hearings, etc. The focus ison the possibility of expressing views for those who would like to be heard. If thosepotentially affected by the healthcare reform have something to say, are they given anopportunity to do that? Did experts holding different views have equal opportunities toparticipate in deliberation?

The third normative criterion is transparency. Deliberative democratic theory stress-es the value of publicity. Deliberative democracy is “an association whose affairs aregoverned by the public deliberation of its members”.8 This criterion requires that thedeliberative process be open to scrutiny by citizens either directly or through the media[19, 20]. Many theorists emphasize the importance of making arguments in publicbecause it is assumed that such arguments are more public-spirited and more mutuallyrespectful. Public proposals—those to be defended before a large and diverse audi-ence—are more likely to appeal to more general principles and to take seriously theviews of opponents [21–23]. Elster also argues that publicity causes policy makers to“replace the language of interest with the language of reason”. 9 Empirically, thecriterion of publicity and transparency deals with the degree of publicity and opennessto the general public of the policy-related political debates. In our case, the existence ofchannels through which common citizens and other groups can observe the process ofhealthcare deliberation and policy-making is a crucial criterion. Timely publication ofrelevant policy documents and inviting the public to provide feedback will indicate thatthe policy process is transparent.

4 Chambers, “Deliberative Democratic Theory.”5 Della Porta, “Deliberation in Movement.”6 Chambers, “Deliberative Democratic Theory,” 322.7 Cohen, “Deliberation and Democratic Legitimacy,” 18.8 Cohen, “Deliberation and Democratic Legitimacy,” 17 (emphasis added).9 Jon Elster, “Deliberation and Constitution Making,” in J. Elster, Deliberative Democracy, 111.

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The fourth criterion is reason and knowledge. The “reason-giving requirement” isconsidered to be at the core of all theories of deliberative democracy.10 Deliberativedemocracy is based on reason, which means that people are convinced by the force ofthe rational argument.11 “Citizens and their representatives are expected to justify thelaws they would impose on one another by giving reasons for their political claims andresponding to other’s reasons in return”. 12 Deliberative democratic theory criticallyinvestigates quality, substance, and rationality of the arguments and reasons brought todefend policy and law. Since these criteria are closely related to knowledge of the issueunder deliberation, a key empirical question here deals with the involvement of peopleor groups with specific competences as well as the intensity of academic support.Active participation in the deliberation process by university professors or any otherexpert groups with specific experience and competence is an important indicator. Howactively have people with specific experience in the healthcare sector been consulted?Was their advice heeded?

The fifth criterion is the transformation of deliberators’ preferences. To be conse-quential, deliberation is expected to change minds and opinions. Deliberation isenvisaged as a “form of discussion intended to change the preferences on the basesof which people decide how to act.”13 Deliberative democracy implies “the transfor-mation of preferences in interaction” [24]. It is “a process through which initialpreferences are transformed in order to take into account the points of view of theothers”, [25] so that a common end or good can be achieved. A more collaborative andtransformative form of deliberation is viewed as having greater potential [26]. Thiscriterion deals with the consequentiality of the deliberative process and can be opera-tionalized as the shifting of emphases in the decision makers’ agenda during the processof deliberation. The consequentiality of the healthcare deliberation in China can bemeasured by comparing the preliminary reform drafts at the beginning of the reformwith the final versions, or by the number of revisions made to the drafts after sessions ofpublic discussions. Did the government change the policy blueprints, and how manytimes? Did the changes follow public consultation sessions?

When applying the criteria elaborated above to our case of healthcare reform, thevery complex institutional conditions of national-level public policy making, whichmay not be conductive to inclusive and consequential deliberation, should be taken intoaccount. “Good deliberation” has mostly been associated with such instances ofcommunication as Deliberative Polls, Consensus Conferences, Citizens’ Juries, Plan-ning Cells, and the like, all of which are, as Dryzek and Goodin put it, “small enough tobe genuinely deliberative, ” and “representative enough to be genuinely democratic”[27]. As mentioned above, deliberative institutions in China have also been associatedwith local (“small enough”) practices. The case of healthcare reform obviously does notsatisfy the “truly deliberative case” criterion.

One way to deal with the issue is to pay attention to the fact that, unlike local, short-term, and small-scale deliberation exercises, national-level public policy making is aprocess that consists of logically distinct phases or stages. Each phase of the process has

10 Thompson, “Deliberative Democratic Theory and Empirical Political Science,” 498.11 Della Porta, “Deliberation in Movement,” 344.12 Thompson, “Deliberative Democratic Theory and Empirical Political Science,” 498.13 Adam Przeworski, “Deliberation and Ideological Domination,” in Elster, Deliberative Democracy, 140.

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its distinct goals and requirements and, therefore, different deliberative qualities.Therefore, the deliberative criteria elaborated above may not be simultaneously present,as they are in the case of small-scale deliberative forums, but enter the process atdifferent stages.14

Introducing the issue of “stages” to the deliberative research may be analyticallyuseful if deliberative approaches are to be effectively applied to the study of nationwidepolicy making. This will allow seeing an instance of public policy decision as adynamic logical progression with different deliberative features appearing sequentially.Transparency and inclusiveness, for instance, are expected to be most pronounced atthe problem definition, agenda-setting and policy evaluation stages, whereas imple-mentation stages will be more closed and insulated from the public but, on the otherhand, rely greatly on professional knowledge and expertise. Evaluating the degree ofdeliberativeness of the whole policy episode would require assembling each stage’sdeliberative qualities together.

Such a “stadial approach” to the process of deliberation is compatible with what hasrecently been called “a systemic approach to deliberative democracy”, which recog-nizes the problem of scale as a continual challenge for deliberative democracy theory[28]. Proponents of the systemic approach suggest that the scale of analysis shouldextend beyond individual deliberative sites to include deliberation that develops amongand between sites and over time. Within this framework, failures in one institution arecompensated for in another one. In other words, a single part of a deliberative system,even if it has low deliberative quality with respect to ideal deliberation, may stillcontribute to the overall deliberativeness of a system. Therefore, “the system shouldbe judged as a whole in addition to the parts being judged independently” [29].

In the case of NHR, some scholars discern five stages: agenda setting—before Oct.2006; option generation, from Oct. 2006 to Feb. 2008; internal discussion of thepreliminary drafts, from Feb. to Sep. 2008; public consultations on the draft, duringOct. and Nov. 2008; and policy implementation—Dec. 2008 to Mar. 2009 [30].15 Dueto different needs in terms of expertise and public engagement, deliberative criteria atone stage differ from those at another.

How Deliberative is the Healthcare Reform in China?

By the time of NHR, China’s medical system has been found to be in profounddisarray. Since the late 1980s, China’s healthcare can in general be characterized bysuch simultaneous macro trends as rapid increase in total healthcare expenditures,proportional reduction of government spending on healthcare, and decrease inhealthcare insurance coverage. All these demonstrated the continuous withdrawal ofgovernment from the healthcare sector [31]. In light of market-oriented reforms,Chinese leaders took significant steps to privatize and marketize healthcare. Theproportion of government funding for public health facilities reduced considerably

14 In fact, deliberative democratic theory does not tell us whether “good deliberation” requires all deliberativequalities to be present simultaneously, or if different deliberative features may enter at different stages of thedecision making process; nor does it define the exact institutional structures enhancing the “deliberativeness”of a policy process.15 See Shaoguang Wang and Fan Peng [30].

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and healthcare, to a significant extent, turned into a revenue-generating activity. InChina, the consequences of these changes included skyrocketing costs of healthcare,increased out-of-pocket payments, pro-rich inequality in healthcare service delivery,inefficient use of medical resources, inadequate health insurance coverage, and perverseincentive mechanisms in the provider payment system and purchasing of healthcareservices. The number of people covered by any kind of medical insurance was shrink-ing. Income had become a decisive factor in determining which people received hospitalcare. The result of these changes was reflected by a popular saying: “kanbing nan,kanbing gui” (it is difficult and expensive to see a doctor). Such a situation threatened toundermine people’s support for market-oriented reforms and considerably challengedthe CCP’s legitimacy. To deal with the issue, the Chinese government declared publichealthcare a social priority and launched the ambitions “New Healthcare Reform” in2006. How did the process of the reform unfold in terms of deliberativeness?

Agenda Setting: The Recognition of Health Policy Failure

By early 2000s, largely as a result of the dramatic increase in the use of the internet inChina, healthcare became one of the top issues of public debate. Professionals andindividual analysts used the internet actively to criticize the dire insufficiency andinadequacy of China’s medical services. The internet has provided a universal platformfor nationwide opinion exchange. Numerous publicly accessible articles, notes, andindividual experiences talking about the “urgent healthcare crisis” or “serioushealthcare challenge,” appeared on the web [32, 33] 16. The outbreak of SARS inMarch 2003, which exposed many serious loopholes in China’s health sector, became astrong impetus that intensified public debates over healthcare-related problems andinduced more analysts and professionals to join the discussion. These developmentsprioritized the place of healthcare on both media and public agendas and stimulatedmore profound social reflection and increased widespread demand for a completetransformation of China’s healthcare. The rapid spread of the internet helpedhealthcare-related problems to achieve a high level of visibility in society. Healthcareproblems have even become proverbial as a well-known countryside saying demon-strates: “Once the ambulance siren wails, a pig is taken to the market; once a hospitalbed is slept in, a year of farming goes down the drain; once a serious disease iscontracted, ten years of savings are whittled away” [34]. Strong dissatisfaction withthe status quo thus totally penetrated the nationwide public space, spurring publicdeliberation and increasing pressure on the government to take decisive policy action.

The “empowered space” as represented by the State Council responded byconducting an increased number of investigations into healthcare-related problems. Inearly 2005, The Development Research Center of the State Council (DRCSC) jointlywith the World Health Organization (WHO) published a study titled “China’s Reformof the Medical and Health System” with the unequivocal conclusion that China’scurrent healthcare policy is not successful [35]. Researchers from the DRCSC, BeijingUniversity, and the Ministry of Labor and Social Security who participated in theproject argued that pro-market policies undermined both the efficiency and fairness ofmedical resource distribution. It was stated that the market orientation of the previous

16 See, for example Zou Yanling [32, 33].

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reforms was “absolutely wrong” because it conflicted with the very nature of publichealthcare: “China’s medical reform is itself badly in need of reform” [36]. At the sametime, some Chinese officials began publicly to criticize the current healthcare system. Asenior State Council researcher, deputy chief of the social development researchdepartment under the DRCSC, Ge Yanfeng, pointed out that the healthcare systemsuffered from major theoretical as well as practical problems, and that it was misled bythe wrong mainstream market theories and related research [37]. In May 2005, anotherofficial, Liu Xinming, Director General in the Department of Health Policy andLegislation of the Ministry of Health, stated that

The government will define the provision of the healthcare service as a publiclyfunded industry.… Government hospital and socially owned nonprofit hospitalswill become the main components of healthcare sector, in order to demonstratethe public service nature of the healthcare sector. For-profit hospitals will play asupplemental role and we will set different policies [38].

Thus, in 2005 the Chinese government openly acknowledged that China’s existingmedical system was a failure in need of an immediate remedy.

In terms of the transparency of the agenda-setting process, the role of public media,especially the internet, as a transmitter of information should be emphasized. Immedi-ately after being submitted to the central government, the above-mentioned DRCSC–WHO report did not attract nationwide attention or provoke active discussion. Soonafter that, however, China Youth Daily (Zhongguo qingnianbao 中国青年报) and othermedia outlets reprinted the main points of the report, and the health reform debatebecame an urgent issue, engaging the whole society in the process of deliberation.17

The Chinese media publicized a vast range of experts’ views and a cascade of criticismof government policies that considerably accelerated the processes of problem identi-fication and the public policy agenda setting.18

17 “Guowuyuan yanjiu jigou: woguo yigai gongzuo jiben bu chenggong (State Council Research Organiza-tion: our country’s medical reform is basically unsuccessful),” Zhongguo qingnian bao (China Youth Daily),28 July 2005.18 This is an unavoidably incomplete list of Chinese media reports published almost simultaneously with theDRCSC–WHO report and publicizing information revealing serious problems in the health insurance realm:“Expert Says China’s Medical Reform ‘Basically Not Successful’,” Xinhua (Online), 29 July 2005; JosephineMa, “Think-tank Lashes the Mainland’s Health Care,” South China Morning Post (Online), 30 July 2005;“Health Ministry Says Rural Medical System Still Facing Several Major Problems,” China Daily (Online), 4July 2005; “Huanzhe, yiyuan, zhenfu wu ren manyi: yigai jiasheng fanyuan zi liangdian mixin (A Half-BakedReform Leaves Patients Unsatisfied, Hospitals Unsatisfied, Government Unsatisfied), Xinhua (Online), 4August 2005; “State Must Lead Medical Reforms,” China Daily (Online), 4 August 2005 (citing YanzhaoMetropolis Daily); “Weisheng buzhang Gaoqiang: zhengfu yinggai jida yiliao touru (Gao Qiang, Minister ofHealth, Urges More Investment in Health Care),” Number One Economic Daily (Online), 5 August 2005;Wang Zhenghua, “Hospitals Overcharge Patients for Profits,” China Daily (Online), 5 August 2005; “GapsWithin Troubled China’s Health Sector,” Xinhua (Online), 8 August 2005; Yigai xin fangan huo niandi qidong(Health Reform Plan to be Launched By End of the Year),” Beijing News (Online), 8 August 2005; “Woguoyin bing siwang de nongcun ertong zhong rengyou yiban wei dedao zhiliao (Half of all Children Who Die ofIllness in the Countryside Had Not Received Medical Treatment),” Xinhua (Online), 17 August 2005; “Yigaide sixue zai near? (What are the Root Problems of Healthcare Reform?).” Southern Weekend (Online), 18August 2005; “Fujian Suicide Bombing: A Wake-up Call for Health-care Reform?” South China MorningPost (Online), 18 August 2005; Zhang Feng, “Rural Kids ‘Need Better Healthcare’,” China Daily (Online), 18August 2005.

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At the same time, the wide spectrum of theoretical approaches that began enteringthe public deliberative space shows an emerging trend towards inclusiveness andplurality. Scholars of different stripes started actively to enter the deliberation processand argue about the possible causes of the failure: was the inadequacy of China’shealthcare sector a result of excessive marketization, as the report concluded?

In this regard, the “left–right” division began to emerge as scholars from both leftand right ends of the political spectrum were becoming active in the debate and able toexpress their arguments in a regular manner. For instance, Tianze Biweekly internetforum (Tianze shuangzhou luntan 天则双周论坛), hosted by the Unirule Institute ofEconomics in Beijing, opened a series of discussions inviting scholars with colludingattitudes to express their opinions concerning better ways of improving China’shealthcare. Professor Gu Xin from the School of Government, Beijing University,argued that the true cause of the failure was not over-marketization per se, but ratherthe fact that it went wrong and took the form of “abnormal marketization” due to thelack of an effective regulatory framework. On the same arguably pro-market side wasProfessor Yu Hui from the Chinese Academy of Social Sciences, who argued in theforum that the anti-market rhetoric of the reform was counterproductive. These andother participants with relatively similar views were labeled the “pro-market school”(shichangpai 市场派). There were also those called the “supporters of the government-led model” (zhengfu zhudaopai 政府主导派). Professor Li Ling from the NationalSchool of Development, Beijing University, argued for a greater role of governmentbecause the healthcare sector by nature suffers from information asymmetry, supplier-induced demand and other market failures. She suggested that the efficient distributionof medical resources was unachievable by market instruments. In a similar vein,Professor Ge Yanfeng from the State Council Development Office also argued thatpro-market orientation is wrong both theoretically and practically.19

It can be seen that different views and attitudes regarding how to reform China’shealthcare sector were present in the public space. Moreover, some of those who wereactive at this stage were invited by the government to participate directly in reformdrafts at later stages of the process. Also, it is worth noting that participants of theforum do not associate themselves with either left or right camps.20 These labels havebeen attached by the general public, who followed the discussion closely based on thedifferences in the experts’ views. It indicates that professional arguments are effectivelytransmitted to wider audiences, which broadens the deliberative space and makes theprocess more transparent and inclusive.

As the agenda-setting process accelerated, the professional knowledge componentbegan to gain greater strength. Independent professionals and research groups began toinfluence healthcare reform via more official channels by reporting the results ofvarious independent case studies exploring both failures and successes of the currenthealth policies to the government. Examples are numerous. One of the most influentialis probably the “Suqian Health Reform Research Report” (Suqian yigaidiaocha baogao

19 For more on Tianze forum deliberation and on how differently oriented experts entered the discussionprocess, see “Zhiku yu yiliao gaige de boyi (Think tanks and the healthcare reform games),” 21 shiji jingjibaodao (21st century’s economic report), 15 April 2009. Available online, http://www.sachina.edu.cn/Htmldata/news/2009/04/5174.html (accessed 1 November 2012).20 Author’s interview with a professor from the School of Government, Beijing University, Beijing, 13 May2011.

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宿迁医改调查报告), conducted by a group of scholars affiliated with BeijingUniversity’s National School of Development. This report, using the case of Suqianpublic hospital in Jiangsu province, has demonstrated that privatization of publichospitals cannot solve the “kanbing nan kanbing gui” (it is difficult and expensive tosee a doctor) problem. The report was publicized through public media and attractedthe government’s attention 21 and, what is particularly relevant for our analysis ofdeliberativeness, was subject to harsh criticism by some bloggers who blamed theauthors for the lack of methodological rigor and incorrect target setting [39].

These efforts to evoke a response from the government were not futile. In June 2006,The State Council established an Inter-ministerial Coordination Working Group(Guowuyuan shenhua yiyaoweisheng tizhi gaige buji xietiao gongzuo xiaozu 国务院

深化医药卫生体制改革部际协调工作小组, The Coordination Group hereafter) responsiblefor conceptual and practical “deepening” of the reform process [40]. Several monthslater, on 23 October 2006, the Politburo held the 35th Collective Study Session thatdiscussed development of China’s healthcare system. At the session, the previouslymentioned Prof. Li Ling and former vice president of the Chinese Medical Association,Prof. Liu Jun, delivered reports on foreign experience in healthcare management andpossible lessons for China. At the end of the session, President Hu Jintao prioritized thepublic orientation of healthcare, provision of all urban and rural residents with basicmedical insurance, and an increase of government responsibility and financial invest-ments into the healthcare sector as basic principles of China’s new healthcare devel-opment [41]. Thus, NHRmoved from the media and public agendas to a policy agenda.This marked the end of the agenda-setting stage. Basic principles described by HuJintao were preceded by a three-month long discussion among representatives ofvarious ministries, academics, and top decision makers. Thus, the 35th collective studysession set an example of making large-scale political decisions by inclusive discussionof different views22—a method adopted at the subsequent stages of NHR.

Deliberativeness of the Policy Formulation Stage (Oct. 2006—Feb. 2008)

The policy formulation stage, which lasted from Oct. 2006 until Feb. 2008, when thefirst complete draft of the reform was generated, represents the most complete set ofdeliberative qualities. The policy process at this stage appears to be more inclusive asthe concretization of the reform draft required greater involvement of the industryassociations and other stakeholder groups. At the same time, inviting the public toexpress their opinions on-line has made this stage more transparent and equal than thefollowing cabinet discussion stage. Finally the evidence of multiple revisions of thereform draft following the discussion sessions with various participants indicatestransformability of the initial positions. Thus, the policy-making process at this stagecan be evaluated in terms of all the above-elaborated criteria of good deliberation.

Beginning with inclusiveness, the policy process included many more stakeholdergroups than in the case of previous large-scale public policy processes in China. The

21 Li Ling, “Beida ketizu suqian yigai diaocha baogao (Beijing University issue group’s research report onhealthcare reform in Suqian),” Zhongguo qingnian bao (China Youth Daily), 22 June 2006. Available online,http://zqb.cyol.com/content/2006-06/22/content_1424541.htm (accessed 28 September 2012).22 Author’s interview in the Department of Government and Public Administration of the Chinese Universityof Hong Kong, 17 April 2010.

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Coordination Group responsible for the process of reform involved 14 ministries andcommissions; then the number increased to 16. The most important in terms of policymaking were five: National Development and Reform Commission, Ministry of Health,Ministry of Finance, Ministry of Agriculture, and Ministry of Labor and SocialSecurity. The other eleven included the State Commission Office for Public SectorReform, Ministry of Education, Ministry of Civil Affairs, Ministry of Personnel,National Population and Family Planning Commission, State Council Research Office,State-owned Assets Supervision and Administration Commission of the State Council,State Food and Drug Administration, State Administration of Traditional ChineseMedicine, China Insurance Regulatory Commission, and the All-China Federation ofTrade Unions. The two other ministries—Ministry of National Defense and Ministry ofHousing and Urban–Rural Development—were also involved, but less directly.23

Discussions of the reform projects also included consultations with the representa-tives of the medical industry. In August 2006, the Coordination Group required theChina Association of Pharmaceutical Commerce to provide reports introducing themedical industry’s vision of the healthcare reform. The Association conducted anindependent survey and requested some member companies to submit their analyses.By late October 2006, four reports had been submitted to the National Developmentand Reform Commission. At the same time, different ministries were arranging forumsand discussions with medical businesses to receive their view on the issue.24

From a deliberative perspective, any nationwide decision-making process can hardlybe thought of as inclusive and equal without active involvement of the general public,who in our case constitute the neediest category. In China, with its large and relativelypoor rural population, which has few opportunities for political access to the decision-making space, a genuine nationwide inclusiveness is difficult to achieve. To obtain abetter grasp of “the needs of the neediest”, Chinese politicians generated the mecha-nism of “going to the masses” which helped to channel public demands to theempowered space.

In fact, collecting opinions from the people is not new to the CCP and goes back tothe tradition of “mass line” (qunzhong luxian 群众路线) or, as some scholars haverecently called it, “qunqicipation”.25 Such a process implies not only public participa-tion, but also a mobilized form of it. Unlike traditional participation, which emphasizesa citizen’s right to seek to influence public affairs through various channels, such asvoting in elections, joining non-governmental advocacy groups, or completing variouspetitions, the Mass Line shifts the emphasis to the responsibility of decision-makers,who must go outside to the masses. The purpose of going into the midst of commonpeople is to cultivate mass-perspective and to gather the ides. One of the key points ofthe Mass Line is that “the ideas of the masses” contain not only their views, opinionsand preferences but also their wisdom and advice. According to Wang, one of the mainadvantages of the Mass Line compared to participation is that it allows the integration

23 Shaoguang Wang and Fan Peng, “Policy Research Groups and Policy Making.”24 Author’s interview with a professor in the School of Public Health of Peking University, Beijing, 17September 2012.25 Coined by CUHK professor Wang Shaoguang, “Qunticipation” denotes a process of politicians going“outside” to stay close to—and gather the ideas of—the masses and to cultivate mass perspective. “Qun”means “mass” (qunzhong 群众). According to Wang, qunticipation usually takes the form of field studies andinvestigations (Author’s communication with professor Wang Shaoguang, Hong Kong, June 2012).

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of the preferences and views of those who, due to lack of time or resources, cannotreach the empowered space. If the government does not descend to the street, manypoor people in remote villages will not be given the opportunity to mount the soap-boxand join deliberation over the issues that are of crucial importance to them. To reach thedecision-making heights, the transmission of signals from below needs to be initiatedby those at the top of the political system.26

In September 2006, the Coordination Group formed four special investigationgroups that conducted fieldwork in more than 20 provinces. Under investigation werethe mechanisms of healthcare system management and functioning, the identificationof better mechanisms of investments into the healthcare sector, the delivery of medicalservices, production and circulation of medicines, and other issues [42]. All majorleaders of the Ministry of Health also traveled throughout the country. Responsible forthe healthcare reform, Vice Prime Minister of the State Council Wu Yi carried out manyfield trips together with academics from different universities in Beijing. Admittedly,such “field trips” do not directly indicate a high level of inclusiveness. This, neverthe-less, points to some desire on the government’s part to accommodate the needs anddemands of all social classes in all regions.

Another instantiation of inclusiveness and equality is the capacity of ordinary peopleto express their views via the internet. On 26 September 2006, the Coordination Groupopened on the official website of the National Development and Reform Commission asection for making suggestions—“Healthcare reform advice and suggestions” (wo weiigai jianan xiance 我为医改建言献策) [43]—here anyone could submit comments orgrievances concerning the healthcare sector. All comments were then categorized intoseveral thematic sections, including the management and effectiveness of the healthcaresystem, the mechanisms of medical care provision, and medical and drug supervision.By December 2006, about 15,000 critical comments and suggestions were solicited; theCoordination Group had also received 600 letters detailing public advice and comments[44]. The Coordination Group systematized all of the feedback and compiled a bookletthat was subsequently submitted to different ministries for reference. Besides theinternet, a public hotline was opened for soliciting opinions and direct communicationson the issues of healthcare reform.

The policy process at this stage was characterized by active involvement ofhealthcare professionals from both inside and outside the country. Many commissionedstudies were carried out with the purpose of developing policy blueprints. At the sametime the Coordination Group was arranging “appraisal meetings” (guotanghui 过堂会)to assess the pros and cons of the suggested reform drafts. Policy makers at differentlevels actively interacted with specialists from international organizations byconducting informal discussions and forums.

Government–academic community interaction is not a new phenomenon in policymaking in China. Previously, however, it was highly dispersed and lacked organization.In the case of the New Healthcare Reform, in contrast, interactions between ministriesand research institutions took place on well-organized deliberative platforms providedby the Coordination Group. Such change has structured the channels of academicinfluence. The interaction has also been transformed from separate single policy-

26 Shaoguang Wang, “Democracy, Chinese Style,” Adelaide Confucius Institute public lecture. Adelaide,Australia 18 September 2012.

162 A. Korolev

making units into inter-institutional coordination units. This has increased both theplurality and diversity of policy discussions as well as the accommodativeness ofreform drafts.

In February 2007, The Coordination Group officially commissioned six Chinese andforeign research institutions to design separately “An overall conception and frame-work of the healthcare reform in China” (Zhongguo yiyaoweishent tizhi gaige zongtisilu he kuangjia sheji 中国医药卫生体制改革总体思路和框架设计). Each institution wasrequired to submit a policy draft reflecting its vision of the reform. These six includedtwo universities (Beijing University and Fudan University), one government researchinstitution (Development Research Center of the State Council), two internationalorganizations (The World Bank and the WHO), and one foreign private consultingcompany (McKinsey & Co) [45].

The fact that it was the Coordination Group which determined the research institu-tions to be commissioned to develop health policy drafts points out the collusive natureof relations between academics and experts in China and the government. Nevertheless,some observations reveal that the deliberation space was not completely closed forthose who did not receive official invitation. It is worth noting that in March 2007 twomore research groups—one from Beijing Normal University and one from RenminUniversity of China—that were not originally included in the list of the commissionedinstitutions also submitted their reform drafts on their own initiative. These institutionsindependently organized healthcare reform research centers and conducted five-month-long research on some pivotal issues of the healthcare reform. To attract the govern-ment’s attention, they organized open discussions of their research results and, as aconsequence, were invited to become official reform draft providers. This has demon-strated that the discussion space is relatively open and can be accessed without initialinvitation. Indeed, following this example, several more research institutions—Tsinghua University, Sun Yat-sen University, [46] 27 Chinese Academy of SocialScience, and the private institution China International Capital Corporation (CICC)—submitted their blueprints and thus squeezed themselves into the policy-making pro-cess.28

After all the policy blueprints had been submitted to the Coordination Group, theState Council organized an appraisal conference on 29–30 May 2007 in the DiaoyutaiState Guesthouse in Beijing. At the conference, representatives of 16 ministries,coordinators of the eight of the above-mentioned research groups, many Chinese andforeign healthcare specialists, as well as Chinese and foreign government advisorsdiscussed the suggested proposals. The conference was chaired by the National De-velopment and Reform Commission and the Ministry of Health. Among the partici-pants were, to name just a few, Maxwell Greg Bloche—President Obama’s senioradvisor on health law and policy; Leonard D. Schaeffer—a founding Chairman andCEO of WellPoint, the United States’ largest health insurance company; William

27 Tsinghua University’s proposal was prepared in cooperation with Harvard University and submitted afterthe appraisal meetings in Beijing in May 2007. It was the ninth policy blueprint submitted to the government.It focused mainly on the healthcare reform experience in other countries and considered the case of China froman international perspective. For more information on Tsinghua–Harvard cooperation, as well as on how otherresearch institutions were submitting their reform proposals, see Wang Yanan [46].28 Author’s interview with a professor in the Department of Government and Public Administration of theChinese University of Hong Kong, Hong Kong, 3 May 2010.

Deliberative Democracy Nationwide? 163

Hsiao—a healthcare economist at Harvard; Hana Brixi—a senior economist at theWorld Bank and advisor to the World Health Organization; Alan Maynard—Professorof health economics at the University of York; Annie Mills—Professor from theUniversity of London, and other Chinese and foreign experts. Each presentation wasfollowed by discussion. An interesting observation relevant to our analysis of deliber-ativeness is that presentations made by Chinese scholars were evaluated by foreignexperts, whereas presentations by the representatives of international organizationswere mainly appraised by Chinese specialists.29 Such cross-evaluation increased mutual“cross-fertilization” of ideas and enhanced the transformability of the originalproposals.

The Chinese government in total received and discussed nine discrete proposals. InSeptember 2007, after having analyzed and run the proposals through the appraisalmeeting process, the Coordination Group generated an “overall plan” of the newhealthcare reform. In October of the same year, the National Development and Re-search Commission conducted two conferences in Nanchang and Tianjin to furtherdiscuss this plan and to circulate it among the leaders of different provinces. InDecember 2007, the Minister of Health Chen Zhu made a report for the StandingCommittee of the National People’s Congress stating that as a result of the analysis ofdifferent proposals and appraisal meetings the preliminary conception and frameworkof NHR in China was now defined. The government should focus on both providersand consumers of the medical services [47].

On 14–15 January 2008, the former Vice Premier of the State Council WuYi directedtwo symposiums where the members of the Education, Science, Culture and HealthCommittee of the National People’s Congress as well as members of the Subcommitteeof Education, Science, Culture, Health and Sports discussed the suggested policy plan.After considering their suggestions, on 29 February 2008 the Coordination Group sentthe revised content to the Standing Committee of the State Council.30 According to thecomments received from the Committee, the Coordination Group revised the draft againand finally formulated the first complete draft of the new healthcare reform—“Sugges-tions on deepening the healthcare reform (preliminary draft for soliciting comments)”(guanyu shenhua yiyao weisheng tizhi gaige de yijian (zhengqiu yijian gao chugao)关于

深化医药卫生体制改革的意见(征求意见稿初稿)). 31 This marked the end of the optiongeneration stage and transition to the next stage of cabinet discussions.

The Stage of Internal Deliberations (Feb.—Sep. 2008)

The preliminary draft of the “Suggestions on deepening the healthcare reform” was stilltoo general and vague. It had integrated various ideas and approaches suggested bydifferent stakeholders and, to become a feasible policy blueprint, needed concretizationand operationalization. All this required healthy interaction between various adminis-trative units and the involvement of experts.

29 Author’s interview with a professor in the School of Public Policy andManagement of Tsinghua University,Beijing, 5 May 2010.30 In light of revisions to the original plan, we can begin talking about consequentiality, or transformabilitycriterion.31 The document was titled “Yijian gao chugao意见稿初稿”, which means not merely “draft”, but “draft of thedraft”: the title explicitly demonstrates that it was a preliminary document that would need to be revised.

164 A. Korolev

These requirements of this policy-making stage have dictated the presence of somedeliberative qualities and the absence of others. Since making policy blueprints morepractically feasible involves highly technical discussions, deliberation at this stageappeared to be less open. On the other hand, however, it may be perceived as moredeliberative in terms of greater cross-fertilization and the transformation of the partic-ipants’ views and preferences as a result of communication between them. The processof seeking common opinion continued, but now it was much more focused and aimedat soliciting views from certain classes and categories of people.

At this stage the main debate concentrated around more concrete questions, such ashow and how much to subsidize, how to redistribute limited financial resourceseffectively, how to coordinate ministerial responsibilities and functions, and how torespond to different interests that became more active at this stage. Discussions overhow to answer these questions took place on and between three levels: ministerial,inter-ministerial, and the level of top decision makers.

At the ministerial level, policy-making units carried out many field investigations andtried to synthesize the collected information by inter-ministerial deliberation. In Sep-tember 2008, Minister of Health Chen Zhu organized ten research groups, each of whichconducted field investigation and studies on ten thematic issues in two or three prov-inces. Reliance on professional knowledge was very high. This time, however, it wasnarrowed to include consultation with policy experts and research institutions directlyattached to the ministries. Such institutions knew all the technicalities of the inter-ministerial games and were able effectively to communicate contentious perspectives.Close attachment to the government ministries, however, considerably limited theirindependence. Experts and research institutions often became unofficial spokespersonsfor all the major ministries and organs of government, and were used to criticize orpersuade potential policy opponents. For instance, the Institute of Health Economics(Weisheng Jingji Yanjiusuo 卫生经济研究所) and the Chinese Research Center for Dis-ease Control and Prevention (Zhongguo Jibing Yufang Kongzhi Zhongxin Yanjiuyuan中

国疾病预防控制中心研究院) were subordinate to the Ministry of Health (MOH) andrepresented its views of the healthcare reform; the Research Institute for Fiscal Science(Caizheng Kexue Yanjiusuo 财政科学研究所) was supporting the Ministry of Finance;experts from the Chinese Academy of Personal Science (Zhongguo Renshi KexueYanjiuyuan中国人事科学研究院) and the Institute of Labor andWages Studies (LaodongGongzi Yanjiusuo 劳动工资研究所) were promoting the agenda of the Ministry of Laborand Social Security; and the Center for Policy Studies (Zhengce Yanjiu Zhongxin政策研

究中心) worked for the Ministry of Civil Affairs.32 Representing different ministries,experts acted as go-betweens in inter-ministerial policy consultations.

Inter-ministerial structures were systematically receiving data from ministries andother structures. From September to October 2008, the Coordination Group receivedcomments from 31 provincial-level divisions, including autonomous regions, and 72ministries and commissions. Suggestions and comments made by the Democratic Partywere also taken into consideration. 33 At this stage, local research institutions alsoactively commenced joining the process of commenting on the “Suggestions” to

32 Shaoguang Wang and Fan Peng, “Policy Research Groups and Policy Making.”33 Author’s interview in the Department of Government and Public Administration of the Chinese Universityof Hong Kong, Hong Kong, 15 May 2010.

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articulate the demands of local governments. Research groups from Beijing enthusias-tically interacted with their local counterparts through a series of focus group meetingsand discussions. In these interactions, local experts were trying to voice the localgovernments’ preferences, whereas center-affiliated researchers were articulating themacro conception of the healthcare reform announced by the top decision makers. Thecollected information was then delivered to the top officials in Beijing. Such interac-tions were expected to help to operationalize the macro policy agenda and, at the sametime, to accommodate regional realities.

Top decision makers also actively traveled across the country and conducted a seriesof forums to communicate directly with grassroots organizations and representatives ofdifferent industries. In April 2008, Premier Wen Jiabao conducted two focus groupmeetings in Zhongnanhai to hear directly from representatives of medical workers,experts and scholars, people in charge of production of pharmaceutical products, newrural cooperative medical scheme staff, migrant workers, neighborhood committeestaff, workers of state-owned and foreign companies, peasants covered by the NewCooperative Medical Insurance Scheme, teachers, presidents of middle schools, drugcompany managers, and others affected by the healthcare reform. An important rolewas played by the Counselors’ Office of the State Council (Guowuyuan canshishi 国务

院参事室), which in July 2008 established a special “public hospital reform researchgroup” and spent five months on investigations and studies of how to reform publichospitals in nine provinces in China. The research group traveled across the countryand held more than 60 seminars and interviewed more than 900 people.34

At this stage, more than 50 corrections had been made to the previous “Sugges-tions.” On 10 September 2008, the State Council held its Executive Meeting and therevised “Suggestions on deepening the healthcare reform (draft for soliciting com-ments)” (guanyu shenhua yiyaoweisheng tizhi gaige de yijian (zhengqiu yijian gao) 关于深化医药卫生体制改革的意见(征求意见稿)) was approved for the next stage.35

Public Consultation Stage (Oct.—Nov. 2008)

The stage of public consultations obviously stands out in terms of inclusiveness,transparency and consequentiality. After having discussed the NHR strategy in theState Council’s backrooms, policy makers decided to expose the renewed “Sugges-tions” to public criticism nationwide via the Internet. The Chinese governmentestablished a web page on which anyone could comment on the most recent reformdraft.

There were several reasons for opening public consultations on the renewed “Sug-gestions.” First, policy makers wanted to gauge the reaction of various stakeholdergroups to the new reform draft. At the same time, public consultations were expected tolegitimize and popularize the project. A better grasp of public feedback was alsoimportant for polishing the draft and making it more balanced in terms of responsive-ness to different interests.

34 Author’s interview with a professor from the School of Public Policy and Management of TsinghuaUniversity, Hong Kong, 19 May 2010.35 These suggestions were different from the previous “suggestions” in that the first draft was titled “Zhengqiuyijian gao chugao征求意见稿初稿” [the draft of the draft], whereas this document was titled “Zhengqiu yijiangao征求意见稿”, simply “draft.”

166 A. Korolev

The exposed healthcare reform draft included some clear programmatic statementson which to comment. It clearly pronounced the establishment of a universal health-insurance system. It was stated that the new plan would provide every citizen withaccess to basic healthcare services that would be affordable, convenient, safe andeffective. To achieve this goal the healthcare plan had 12 major policy interventions,such as the expansion of insurance coverage through premium subsidies; the control ofdrug prices, and the establishment of essential medicine policy; strengthening publichealth and health education; the gradual separation of prescribing from dispensing; theencouragement of vertical integration; the gradual implementation of provider paymentreform; strengthening rural medical infrastructure; establishing a network ofcommunity-based health centers; encouraging the development of the private sector;modernizing medical information systems; strengthening medical education; and im-proving professional ethics [48].

Those who provided feedback criticized the proposed draft for the lack of specificity.It was criticized for lacking a concrete timeline and strategies for implementingproclaimed policies as well as the absence of a price tag for the new programs.Participants of the internet discussions were demanding that policy makers devise moreconcrete and innovative action plans to achieve the lofty goal of better health care forall [49].

As to inclusiveness, the activity of soliciting opinions collected large numbers ofopinions and suggestions from people of diverse professional and social backgroundsand on various healthcare-related issues. According to the analysis provided by theNational Development and Reform Commission, during the period from October 14 toNovember 14, 2008—the period of soliciting public comments on the reform draft—intotal 35,929 comments were solicited, among which 31,320 were submitted via theinternet, [50] 548 by fax, and 4,025 by post. Fifty-five per cent of all submittedcomments belonged medical staff; 20% of feedback was provided by peasants,migrant-workers, workers at different enterprises, etc. In terms of socio-economicstatus, most of those who expressed their opinions were citizens of low or middleincome; 95% of all contributors had an annual income less that 50,000 Yuan (approx-imately 8,000 USD). The age was mainly between 15 and 59 years old; this age groupconstituted 97% of all participants. The most elderly participants preferred to send theirhealthcare demands by post. Feedback was received from different provinces, auton-omous regions, direct-control municipalities, residents of Hong Kong, Macau, Taiwan,as well as overseas residents. According to the government data in terms of content,37.8% of all critical comments concentrated around the issue of improving the medicalservice delivery system; 25.9% of suggestions were related to the issue of strengtheningthe medical insurance coverage; 24.7% focused on the problems related to medicineaffordability and supply; and 8.4% of feedback dealt with the insufficiency of publicsanitation services [51].

Not only did the general public comment on the “Suggestions.” This stage ofhealthcare reform was also characterized by close interaction between independentexperts and interest groups. As noticed by some observers, Chinese pharmaceuticalwholesalers and retailers closely cooperated with pro-market researchers to criticize thereform draft for not emphasizing the importance of market mechanisms in healthcare.By organizing media conferences and submitting written statements to the authorities,some pro-market experts and interest groups attempted to affect public policy discourse

Deliberative Democracy Nationwide? 167

and make healthcare reform more industry-oriented.36 While articulating alternativeviews of the reform, this activity, however, had limited impact and could not change thegeneral conception of NHR, which had already taken shape at the previous stages.

Along with the process of public consultations, the Coordination Group continuedconducting fieldwork and focus group meetings with relevant ministries and localgovernments. Based on the collected information, the Coordination Group has mademore than 50 corrections to the draft. At this stage, the Central Government also beganlaunching healthcare pilot projects in some regions of China to trial the deliberatedpolicy in practice.

In March 2009 the Chinese government announced a new version of “Suggestionson Deepening Healthcare Reform” that emerged as a result of 137 amendments.Admittedly, grasping the influence of public opinion on this new healthcare reformplan is a difficult analytical task. The number of amendments made, however, demon-strates that work on the final version of the draft was not a one-step process and wascharacterized by balancing different interests and looking for compromises betweenthem. The very fact of inviting ordinary people to participate in the development ofnational-level public policy and creating channels for them to submit their grievancesand demands to the policy makers on such scale is unprecedented in post-reform China.This may be expected to increase consensus for the reform and enhance the newhealthcare system’s responsiveness to the people’s needs. Also, it is likely to reducethe probability of unchecked mistakes during the implementation process.

Policy Implementation (March 2009 to 2013)

The result of the work conducted at all previous stages was the adoption of several finaldocuments that marked the commencement of the implementation stage. On 21 January2009, Premier Wen Jiabao chaired a State Council Executive Meeting that passed twopolicy documents: “Guidelines on Deepening the Reform of the Healthcare System”(Guanyu shenhua yiyao weisheng tizhi gaige de yijian 关于深化医药卫生体制改革的意

见) and “Implementation Plan for Deepening the Reform of the Healthcare System”(2009–2011nian shenhua yiyao weisheng tizhi gaige shishi fangan 2009–2011深化医药

卫生体制改革实施方案). Soon after that, on 17 March 2009, the Chinese governmentadopted the “Opinions of the CCP Central Committee and the State Council onDeepening the Healthcare System Reform” (Zhonggong zhongyang, Guowuyuanguanyu shenhua yiyao weisheng tizhi gaige de yijian 中共中央、国务院关于深化医药

卫生体制改革的意见) [52] and “Implementation Plan for the Recent Priorities of theHealthcare System Reform” (Yiyao weisheng tizhi gaige jinqi zhongdian shishi fangan(2009–2011) 医药卫生体制改革近期重点实施方案(2009–2011) [53].

The basic principles declared in these documents are strongly publicly-oriented andreflect the public preferences solicited during the previous policy-making stages. Thekey element of the unveiled documents was the promise of affordable basic healthcarefor everyone. As stated in the documents: “in promoting the establishment of a basicmedical security system, all urban and rural residents will be included into the system toeffectively reduce the burden of drug expenses on the individual” [54]. In order to

36 Shaoguang Wang and Fan Peng, “Policy Research Groups and Policy Making.”

168 A. Korolev

realize these ambitious goals, the government invested an additional 850 billion Yuan(124 billion USD) for the reform.

Based on the analysis of relevant documentation, it seems that the key aspects ofNHR reflect the opinions of the “supporters of the government-led model” (zhengfuzhudaopai 政府主导派), who argued for a greater role of government and criticized pro-market orientation of the healthcare sector. The documents conceptually established agoal of making China’s healthcare system a public good—a conceptual change com-pared to the market-oriented approaches of the 1980s and 1990s. At the same time, theNHR is characterized by a higher level of insurance pooling and increased centralgovernment subsidies. According to the documents,

the government will provide fully from the budget the costs of specialized publichealth institutions related to staffing, development and construction, generaladministration expenses and business operation, and the service revenue of theseinstitutions shall be turned over to a special fiscal account or integrated intobudget management.37

The policy guidelines also require governments at different levels to rearrange theirexpenditure structure and reform the compensation methods to ensure funding for thereform. Attention is also paid to the “vacuum zone”—mainly retirees of bankrupted andclosed-down enterprises in financially-constrained regions who have trouble withentering different insurance plans due to high premiums. To guarantee their entitlementto the benefits of basic insurance plans, the central government promised to providethem with appropriate subsidies.38

Conclusion

This paper is a preliminary attempt to apply general principles of deliberative demo-cratic theory to the case of China’s healthcare reform and to evaluate its relativedeliberativeness. By focusing on NHR, it explored the innovations of national-levelpolicy consultations and public deliberation in China. Deliberative criteria require morespecification in order to be broadly applicable to nationwide policy making in non-democratic regimes. The above analysis, however, shows that the process of the NHRpossesses many features usually associated with inclusive and consequentialdeliberation.

In the case of NHR, the complexity of a national-level public policy issue was dealtwith by relatively open deliberative practices that involved various stakeholder groups.Public participation emerged as an important feature of public policy making in China.The use of network media as a transmitter of different views made it possible toconstruct visible public spaces and include the views of various stakeholders into thepolicy process. Public decision making has become more inclusive and pluralistic thanit was in the past.

37 Ibid.38 Ibid.

Deliberative Democracy Nationwide? 169

At the same time, the extensive involvement of scientific expertise and academicsupport enhanced the quality of policy-making discourse. Numerous consultations,amendments and revisions of the reform plan along the way, in turn, have shown atendency towards more consensual policy-making methods aimed at finding a commonground acceptable for all—at least for those participating—affected by the healthcarereform. It has also demonstrated the transformation of participants’ preferences towardsperceiving healthcare as a public good.

Some argue that China’s current experiment in “healthcare democracy” might fail.39

Public expectations might be too high to meet; interest groups could be too diverse tobalance. Frustrated by this, the Chinese government may decide to suspend its attemptsto include different stakeholder groups in policy making. But, if the process isperceived to be informative, with new and better ideas eventuating; if it can help toprepare the masses for and obtain their support in implementing the new policies; if itcan help to increase people’s trust in and thus strengthen the government’s legitimacyand effectiveness to govern by establishing a new image of transparency; then theexperiment could have powerful spill-over effects beyond the health sector. Should thebenefits from this experiment become clear without incurring out-of-control costs, boththe government and the people could be encouraged to trial a similar approach toreforming China’s education, social security, and even its political systems. This wouldindicate the extent to which transformation of China’s political system is taking a newdirection. “The flood gates of democracy will have been opened, which, once open,might be hard to close again”.40

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32. Yanling, Zou. 2002. Chayi xuanshu: Zhongguo weisheng baojian shiye mianlin yanjun tiaozhan (GreatDisparities: Chinese Healthcare Faces Serious Challenges). Zhongguo gaige (Chinese reforms) 4(7): 8–10.

33. Linlin, Hu., and Hu. Angang. 2003. Cong bu gongping dao gengjia gongping de weisheng fazhan:Zhongguo chengxiang jibing moshi chaju fenxi yu jianyi (From Unfair to More Fair HealthcareDevelopment: The Analysis of Differences in Diseases Patterns in Cities and Villages). Guanli shijie(Management world) 1: 78–87.

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35. Guowuyuan fazhan yanjiu zhongxin ketizu (Issue Group of the Development Research Center of the StateCouncil), “Guowuyuan yanjiu jigou dui Zhongguo yiliaogaige de pingji yu jianyi (State Council ResearchInstitutions Appraisal and Recommendation of Healthcare Reform in China),” 25 July 2005. Availableonline, http://www.southcn.com/nflr/llzhuanti/ylgg/tbgz/200509140346.htm (accessed 15 September2012).

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36. “Expert says China’s medical reform ‘basically not successful’,” Xinhua, 29 July 2005. Available online,http://english.peopledaily.com.cn/200507/29/eng20050729_199135.html (accessed 22September 2012).

37. Ge Yanfeng, “Muqian Zhongguo de yigai jiben shang shi bu chenggong de (The current healthcare reformin China is basically not successful),” Nanfang wang (South.com), 29 July 2005. Available online, http://www.southcn.com/nflr/llzhuanti/ylgg/tbgz/200509140214.htm (accessed 23 September 2012).

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41. “Zhonggong zhongyang zhengzhiju di 35 ci jiti xuexi (the 35th collective study of the Centralgovernment),” Xinhua, 24 October 2006. Available online, http://news.xinhuanet.com/video/2006-10/24/content_5244468.htm (accessed 22 September 2012).

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10197534.htm (accessed 0 October 2012).45. The US–China Business Council 2009, State Council Leading Group for Coordinating Healthcare System

Reform. Available online, https://www.uschina.org/public/documents/2009/06/healthcare_leading_group.pdf (accessed 21 October 2012).

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48. State Council Healthcare Reform Leadership Coordination Group’s draft for soliciting public feedback.Available online, http://shs.ndrc.gov.cn/yg (accessed 23 October 2012).

49. Different suggestions and criticisms by people are available in Chinese on the official website of theNational Development and Reform Commission of the PRC. Available online, http://www.ndrc.gov.cn/ygyj/ygyj_list.jsp?&type=1 (accessed 22 October 2012).

50. This internet submission occurred by means of a specific webpage hosted by the National Developmentand Reform Commission: anyone who wanted to provide criticisms or recommendations could do soonline by identifying him or herself and inputting text. Public comments and suggestions are still publiclyavailable online: http://www.ndrc.gov.cn/ygyj/ygyj_list.jsp (accessed 23 October 2012).

51. The analysis of the public feedback on the reform draft is available on the Central Government webpage,http://www.gov.cn/jrzg/2008-11/15/content_1150149.htm (accessed 24 October 2012).

52. The Central Government of the PRC, 6 April 2009. Available online, http://www.gov.cn/jrzg/2009-04/06/content_1278721.htm (accessed 24 October 2012).

53. The Central Government of the PRC, 7 April 2009. Available online, http://www.gov.cn/zwgk/2009-04/07/content_1279256.htm (accessed 24 October 2012).

54. Implementation Plan for the Recent Priorities of the Health Care System Reform (2009–2011). Availableonline, http://www.china.org.cn/government/scio-press-conferences/2009-04/09/con-tent_17575401.htm(accessed 26 May 2010).

Alexander Korolev is Associate Professor of political science at the School of Asian Studies of the NationalResearch University Higher School of Economics (Moscow), and is currently a post-doctoral fellow at theCenter on Asia and Globalization at the National University of Singapore. His research interests includedemocratic theory, international relations and politics in China.

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