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Lv, Aofei (2015) Explaining Health Policy Change in China Between 2003 and 2009: Actors, Contexts and Institutionalisation

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Lv, Aofei (2015) Explaining Health Policy Change in China Between 2003 and 2009: Actors, Contexts and Institutionalisation Lv, Aofei (2015) Explaining health policy change in China between 2003 and 2009: actors, contexts and institutionalisation. PhD thesis. http://theses.gla.ac.uk/6651/ Copyright and moral rights for this thesis are retained by the author A copy can be downloaded for personal non-commercial research or study, without prior permission or charge This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given. Glasgow Theses Service http://theses.gla.ac.uk/ [email protected] Explaining Health Policy Change in China between 2003 and 2009: Actors, Contexts and Institutionalisation Aofei Lv MA (Hons), MSc in Political Science Submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy (Politics) College of Social Sciences School of Social and Political Sciences University of Glasgow May 2015 2 Abstract The health policy change in China between 2003 and 2009 was profound. In 2003, the Chinese government changed its response to the Severe Acute Respiratory Syndrome (SARS) outbreak from initial passivity to proactivity. Following the SARS outbreak, in 2005 the Chinese government started major healthcare reforms. During this process, the health policy direction then changed from marketisation towards being more government- led. Previous research has explained health policy change mainly from bureaucratic perspectives that considered the government playing the main role. This thesis explains how and why health policy changed by focusing on three actors outside the political system. I argue that, after the SARS outbreak, experts, the media, and international organisations influenced the health policies as a ‘Policy Entrepreneurial Coalition’ (PEC), the result of which was a combination of normal and paradigmatic policy changes between 2003 and 2009. This is a qualitative study. I conducted fieldwork in China involving semi-structured interviews of policy insiders and outsiders. The policy insiders are government officials in the Ministry of Health. The policy outsiders are: domestic Chinese experts in social science, health economics, and health; external (foreign) experts who were involved in China’s health policymaking; journalists in national media and other commercialised traditional media; and representatives of international organisations in China. I also did content analysis of both policy documents and media reports. I identified three cases: the health policy change during the SARS outbreak, the initiation of the healthcare reform, and the health policy change during the healthcare reform policymaking. This thesis makes three major contributions. First, it documents the health policy change between 2003 and 2009. Second, previous studies focused on bureaucratic bargaining during policymaking in China, but I examine roles of policy outsiders, who have conventionally been neglected in China’s policy process. Third, to explain the influence of the outsiders, I examine the policymaking process within the central government and how the policy outsiders interacted with the policy insiders. In doing so, this thesis contributes to the understanding of China’s politics and policy processes. 3 Table of Contents Abstract .................................................................................................................................. 2 List of Tables.......................................................................................................................... 6 List of Figures ........................................................................................................................ 6 List of Pictures ....................................................................................................................... 7 List of Graphs ......................................................................................................................... 7 Acknowledgements ................................................................................................................ 8 Author’s Declaration ............................................................................................................ 10 Main Abbreviations .............................................................................................................. 11 1 Introduction ................................................................................................................... 12 1.1 Approaches to the explanation of policy change ................................................... 15 1.1.1 Process approach to policy change ................................................................ 15 1.1.2 Actors approach to policy entrepreneurship .................................................. 18 1.2 Understanding China’s political system: an authoritarian state ............................ 21 1.2.1 Fragmented authoritarianism ......................................................................... 21 1.2.2 Outsiders’ influence on the policy process in China ...................................... 22 1.3 Explaining the argument ....................................................................................... 24 1.4 Analytical Framework ........................................................................................... 26 1.5 Methodology ......................................................................................................... 28 1.6 Structure of the thesis ............................................................................................ 31 2 The context of the PEC’s influence and the health policy change ............................... 34 2.1 Historical background ........................................................................................... 35 2.2 Ideology ................................................................................................................. 36 2.3 Political system ...................................................................................................... 41 2.3.1 Leadership transition ...................................................................................... 41 2.3.2 Fragmented authoritarianism ......................................................................... 43 2.4 Institutional design of the central bureaucracies in health .................................... 47 2.4.1 Central apparatus and hierarchy of health policies ........................................ 48 2.4.2 Functional differentiation ............................................................................... 51 2.4.3 Policy community .......................................................................................... 53 2.5 Rationale for choosing the three types of policy outsiders for consideration ....... 55 2.5.1 Technocracy ................................................................................................... 56 2.5.2 Three types of outsiders with their own expertise ......................................... 57 2.6 Summary ............................................................................................................... 64 4 3 Health policy change in China from 2003 to 2009 ....................................................... 67 3.1 Health policy change ............................................................................................. 67 3.2 Health policy change in China from 2003 to 2009 ............................................... 69 3.2.1 The change in SARS treatment policies......................................................... 69 3.2.2 The change of SARS control policies ............................................................ 71 3.2.3 The change in health information reportage policies ..................................... 74 3.2.4 The health policy change during healthcare reforms ..................................... 79 3.3 Paradigm shift in the health policy’s overarching goals ....................................... 85 3.3.1 The goal change in communiqués of the CCPNC ......................................... 85 3.3.2 The goal change in working reports of the NPC ............................................ 87 3.4 Summary ............................................................................................................... 90 4 The PEC’s influence on SARS policy change .............................................................. 91 4.1 The problem stream ............................................................................................... 92 4.1.1 Direct involvement of experts in Guangdong ................................................ 93 4.1.2 Indirect involvement of the media and the International organisations ......... 95 4.2 The policy stream in the middle of SARS ............................................................. 96 4.2.1 Debate among experts about SARS treatment policies.................................. 97 4.2.2 Breakthrough of the media ............................................................................. 99 4.2.3 Involvement of the WHO ............................................................................. 103 4.3 The political stream and policy change in the final stage ................................... 109 4.3.1 Expert’s direct influence on SARS control
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