The tendency to credit Hu Jintao 胡锦涛 and Wen Jiabao 温家宝 with the social policies of their decade in power is in part a convenient shorthand. But while it is unlikely that major policies would have been adopted or implemented nationwide had China's top leaders opposed them, accounts that focus exclusively on Hu and Wen perpetuate an understanding of policymaking as straightforwardly controlled, top-down, by those at the very apex of the political system. Such accounts have their roots in the politics and scholarship of the pre-reform “Maoist” period,Footnote 1 when a combination of Mao Zedong's 毛泽东 penchant for playing a direct role in policymaking, and limited access to China by foreign scholars, resulted in a concentration on his part in driving many policies. Variants of this understanding of Mao-era policymaking focussed on factional power politics among the Chinese leadership or portrayed policy as the product of leaders’ rational, problem-solving calculations.Footnote 2
Challenging top leader-centred explanations are those that have focussed on bureaucratic actors. Early studies of the bureaucracy and of political organization,Footnote 3 when combined with greater access to China from the late 1970s, evolved into influential work that in the late 1980s characterized policymaking as shaped by “fragmented authoritarianism.”Footnote 4 This characterization emphasizes the decisive roles of bureaucratic actors and institutional arrangements (systems of rank, functional divisions of authority, and decentralization) and portrays intra-bureaucratic bargaining as important in shaping policy. Based on a study of economic decision making and large-scale energy policies that were important not only to some of China's top leaders but also to certain provincial governments and ministries, the model might work less well for other policy areas.Footnote 5 But there have been few formal or detailed attempts to test it in other policy arenas.Footnote 6 Instead, it has remained the dominant model of policymaking,Footnote 7 and has been modified since the early 1990s only to take account of the influence of domestic “policy entrepreneurs” – whether individual officials, journalists, editors or non-governmental organizations – who are portrayed as taking advantage of the spaces created by institutional fragmentation. In studies ranging across environmental, trade, housing and anti-poverty policies, these studies show how domestic actors have used their knowledge of bureaucratic structures and ways of working to promote their own interests or policy agendas.Footnote 8
This article assesses the utility of “fragmented authoritarianism” and its key rivals, the leadership power and rationality models of policymaking, through a study of a major domestic social (and healthFootnote 9) policy often credited to the Hu–Wen leadership – New Rural Cooperative Medical Schemes (NRCMS; xinxing nongcun hezuo yiliao 新型农村合作医疗). It looks at all three models because although fragmented authoritarianism still dominates scholarship on Chinese public policy, leadership power and rational explanations are common in both scholarly and media accounts of Chinese politics and policymaking – and, as we shall see, have been used to explain China's 21st-century social policies, including NRCMS.
The article focuses on NRCMS case for several reasons. It was an early policy (trialled from 2003 and implemented nationwide from 2005) of the Hu–Wen period, and it was closely related to the major initiative to “Build a new socialist countryside” (announced in early 2006). It was important because it not only aimed to provide health insurance to all rural residents, but also rolled out for the first time in the post-Mao period a (partially) government-funded universal rural social programme. It was then followed by others, most notably means-tested income support and pensions for rural dwellers. But it was with NRCMS that the Party-state for the first time established the entitlement of this previously marginalized (though numerically significant) segment of the population to government-funded social provision.
Using NRCMS as a single case to test explanations of policymaking has both advantages and limitations. It allows this article to present more detail, but it also means that its findings need further testing in other cases. NRCMS is a “hard” case for a test of leadership power explanations due its strong association with Hu Jintao (usually portrayed as in the opposing faction to his predecessor, Jiang Zemin 江泽民) and Wen Jiabao. It is also a hard case against which to test the “rational” explanation, given that it aimed to address a particular social problem. But it is a “soft” case for testing the bureaucratic bargaining explanation, since it does not (like economic or energy policy) involve competition over significant assets or resources. The article therefore presents a potentially stronger challenge to factional and rational models, but it cannot fundamentally challenge bureaucratic bargaining models that may work well in policy arenas that (unlike NRCMS) generate greater intra-bureaucratic competition. Its own propositions about international influences and policy networks must also be tested through examination of other cases.
Methodologically, the article draws on recent attempts in political science to strengthen qualitative case study analysis by using process tracing to evaluate competing hypotheses.Footnote 10 It uses previous explanations of the adoption of NRCMS to establish hypotheses,Footnote 11 but it identifies others from a combination of prior theoretical knowledge and detailed understanding of the case. The analysis proceeded as follows. I first traced the evolution of the policy from its beginnings in the 1980s through to the mid-2000s (when it was rolled out nationwide) using Party and government policy documents, the reports of international organizations, Chinese newspaper articles and scholarly papers. Having drawn up a policy timeline (for a greatly simplified version see the Appendix to this article), I identified key decision points in the policy's evolution, and the actors involved around those decision points. I was also able to identify changes to the policy's content (for example the shift from township to county level administration, and from individual to combined individual-and-government funding) and to the official rationale for the policy.
Using this timeline, I evaluated prior explanations and identified new actors and influences on the policy so as to generate a new explanation of its development and a new model of policymaking. In so doing I was alert to the potential influence of factors identified in policy research elsewhere, particularly those relating to policy networks and the influence of ideas in policymaking.Footnote 12 These factors and concepts are rarely deployed analytically in Chinese policy research.Footnote 13
The rest of the article proceeds as follows. It first gives an overview of key events in the evolution of what became NRCMS. It then elaborates the three dominant models of policymaking in China and their actual or hypothetical competing explanations of NRCMS.Footnote 14 The article then assesses the evidence for these explanations, before setting out an alternative that highlights international influences – organizations operating within policy networks and their ideas, as well as international events and interpretations of them. The article concludes by discussing the changing significance of international influences over time and proposes a new model of the policy process – network authoritarianism.
New Rural Cooperative Medical Schemes: A Brief Timeline
New Rural Cooperative Medical Schemes were adopted as national policy and implemented nationwide in the first decade of the 21st century. But they can be traced back to Rural Cooperative Medical Schemes (RCMS, nongcun hezuo yiliao 农村合作医疗) adopted from the late 1950s and extended during the Cultural Revolution to around 80 per cent of villages.Footnote 15 These schemes were, however, allowed to collapse in the early 1980s, so that by 1984 they existed in only about 5 per cent of villages.Footnote 16
From 1985, the Chinese Ministry of Health, with advice and support from the World Bank and the Rand Corporation, began exploratory experiments with commercial insurance alternatives to RCMS.Footnote 17 But by 1991, during a pause in pro-market reforms following the 1989 Tiananmen protests and crackdown, RCMS emerged as the preferred policy – backed by Li Peng 李鹏 and the Ministry of Health.Footnote 18 In the early 1990s, Ministry of Health-led experiments with RCMS began, and in January 1997 the Party Central Committee and State Council issued an authoritative “Decision” (jueding 决定) that announced nationwide voluntary RCMS experiments and the goal of extending schemes to all rural residents by 2000.Footnote 19
With only a few exceptions, however, localities failed to implement experiments in the late 1990s because the Party-state centre simultaneously pushed forward tax-for-fee reforms aimed at reducing unpopular local government levies that were said to be creating unreasonable burdens for farmers.Footnote 20 The centre then issued a Notice in July 1998 that made clear that local governments should not gather fees (which included RCMS contributions).Footnote 21 RCMS was quietly dropped until May 2001 when it once again appeared in “Guiding opinions on rural health work” drawn up by the State Council Economic System Reform Office, State Planning Commission and Ministries of Finance, Agriculture and Health.Footnote 22
In January 2002, nine months before Jiang Zemin stepped down as General Secretary of the Chinese Communist Party (CCP) and Hu Jintao took over that role, Vice-premier Li Lanqing 李岚清 ordered the formulation of rural health reform policies including rural health protection. This led to an October 2002 Party Central Committee and State Council Decision announcing rural health reforms and “new” RCMS (NRCMS) just before Hu Jintao took leadership of the CCP.Footnote 23 NRCMS differed from RCMS (in 1997) in two key ways: first, it was organized by county governments, rather than by townships; second, it involved government funding alongside voluntary farmer contributions.Footnote 24
The 2002 Party-state Decision, unlike its 1997 predecessor, was soon followed by “Opinions” to push the implementation of local experiments. In January 2003, two months before Wen Jiabao became premier, the State Council ordered each provincial level government to select two or three counties to pilot NRCMS,Footnote 25 and then ordered the creation of NRCMS coordinating committees.Footnote 26 Experiments began that year, and were then extended. In September 2005, the Party-state centre reviewed the experiments at a National NRCMS Pilot Work Conference and announced the goal of adopting the programme nationwide by 2008, ahead of the original schedule of 2010.Footnote 27 By 2008 NRCMS had extended a measure of health risk protection to almost all the rural population.
Explaining the Adoption of NRCMS
Leaders and factional power explanations
Factional explanations have typically argued that a policy is adopted by one group of leaders “to rebuff a challenge from rivals,” or by a faction “for the rewards it bestows upon its network of loyalists.”Footnote 28 Such explanations were found in work on major policy shifts from the 1970s through into the 1980s,Footnote 29 but they have become much less common in policy analyses since then.Footnote 30 And when factions – notably the Shanghai Clique, “Youth League” faction, and “Princelings” – are mentioned, they are portrayed as more fluid than in the Mao and early post-Mao periods.Footnote 31
Although factional power rivalries have not been used to explain the adoption of NRCMS in 2002, factions have been mentioned in connection with the social policies of the 2000s that include NRCMS. Shaun Breslin has argued, for example, that Hu's social policies marked a distinct shift by the “Youth League” faction toward tackling inequality and deprivation and away from the economic growth-focussed policies of Jiang Zemin and the Shanghai clique.Footnote 32 Cheng Li, meanwhile, has argued that Hu Jintao's lack of factional support in the top echelons of the CCP motivated him to use social policies to generate popular support.Footnote 33 Neither, however, provides evidence for his claim.
In fact, factional power plays do not provide a satisfactory explanation of the adoption and extension of NRCMS in the early 2000s under Jiang Zemin and then Hu Jintao. Jiang Zemin is usually associated in factional analyses with the Shanghai Clique, and his successor as President and CCP General Secretary, Hu Jintao, with the rival Youth League faction. Yet, Jiang backed RCMS in 1996 and then revived it in 2001. He (and Premier Li Peng) attended a national health conference in December 1996 at which he spoke in support of RCMS.Footnote 34 Jiang has also been specifically linked to putting it back on the central government agenda in late 2001.Footnote 35 NRCMS policy was then formulated under his leadership from January 2002 and adopted in October that year, just before the 16th Party Congress in November at which Jiang stepped down and Hu took power. Measures to implement and extend the policy were sustained under Hu into 2003 and beyond.
Leaders and rational explanations
“Rational” explanations portray policies as responses to objectively existing economic, social or political problems. In some variants, the decision makers are simply “policymakers” or “the government,” and their motives are not explored. Such explanations are often implicit in studies that describe rather than analyse policies, and are common in work by scholars who focus on improving policy rather than analysing how it is made. In other variants, top leaders adopt policies “pragmatically to solve new policy problems” or in order “to keep alive [their] ideological vision.”Footnote 36 Work making these arguments often focuses on leaders and their values and preferences.Footnote 37 Others consider their background and experience. The economic growth-focussed policies of the Jiang and Zhu period are thus sometimes linked to their urban, coastal leadership experience, while Hu and Wen's focus on rural social policy is portrayed a result of their background in poor rural areas and agricultural affairs.
Rational explanations are evident in accounts of NRCMS – particularly those that are concerned more with its outcomes than with why it was adopted.Footnote 38 But others interested in explaining the evolution of RCMS and eventual adoption of NRCMS have also sometimes used them. Chief among them is Wang Shaoguang, who has argued that the Ministry of Health and then central government policymakers “learned” from research and policy experimentation that RCMS was better than user-pay systems first. Top policymakers then learned from further experimentation that cooperative schemes needed government funding to make them work, and they agreed to such funding after fiscal revenues grew in the early 2000s.Footnote 39 Thus the government is portrayed as dealing with a social problem once it has the right policy and the finance to do so.
Wang's study provides a fascinating account of the evolution of RCMS experiments, and it argues persuasively that the central government's improving fiscal situation was conducive for implementing government-subsidized NRCMS. But fiscal revenues rose as a share of gross domestic product from 1997 onwards, and leaders could have chosen to spend on any number of projects and policies. Fiscal capacity is therefore an important contextual variable, but it does not explain why a decision was taken in 2002 (rather than earlier or later) to adopt NRCMS, and why it was prioritized over other policies (such as rural pensions).Footnote 40 While Wang demonstrates the Chinese governance system's extraordinary capacity for experimentation, research and extensive discussion of some policy options, his account also tends to idealize that process – as if the adopted policy is the correct one, when as others have argued, some aspects of NRCMS were flawed: its focus on catastrophic, inpatient care, and its limited funding compared with urban programmes.Footnote 41
Bureaucrats, policy entrepreneurs and fragmented authoritarian explanations
The “fragmented authoritarian” portrayal of policymaking directed attention in the late 1980s to bureaucratic actors and institutions as an important corrective to studies that had focussed on leaders.Footnote 42 This sophisticated work revealed how policy outcomes were strongly influenced by bargaining among competing bureaucratic agencies – including central ministries and provincial governments. It showed that the system of bureaucratic rank meant that when agencies of the same rank disagreed on an issue or policy, it would be passed upward to top leaders to coordinate, mediate or adjudicate. As a result, it argued, policy processes were “diffuse,” “protracted,” “incremental” and “disjointed.”Footnote 43
Although fragmented authoritarianism and bureaucratic bargaining has not been explicitly invoked to explain the making of RCMS or NRCMS policy in the 1990s and 2000s, some accounts do focus on bureaucratic actors. Armin Müller, for example, characterizes the development of NCRMS as shaped by bureaucratic actors taking competing pro-government (in favour of state-funded CMS) and pro-market (in favour of commercial insurance) positions.Footnote 44 His focus is on key central government agencies that tended to favour one position or the other – the Ministry of Health in favour of CMS, for example, and the Ministries of Agriculture and Finance in favour of commercial health insurance. Müller portrays these bureaucratic positions as based on institutional perspectives – the Ministry of Agriculture wanting to reduce farmers’ burdens and so against compulsory farmer contributions to CMS, the Ministry of Finance against large budgetary commitments – but also sometimes influenced by ministers’ alliances with other leaders.
Bureaucratic actors certainly were important. The Ministry of Health was charged with RCMS work from the 1980s through to the late 1990s, leading experimental studies and formulating RCMS policy documents. The State Council Economic System Reform Office (ESRO) and its drafting group in 2002 coordinated NRCMS policy formulation and negotiation.Footnote 45 Policy documents setting out both RCMS and NRCMS policy were often issued under the joint names of several ministries, including the Ministry of Agriculture and Ministry of Finance, indicating that they had been involved in producing them.Footnote 46
There is also some evidence of bureaucratic bargaining over the details of RCMS and NRCMS. In both programmes, farmers contributions were stipulated to be voluntary as a concession to the Ministry of Agriculture, because mandatory contributions would have undermined that Ministry's efforts to reduce local government fees and the “farmers’ burden.”Footnote 47 In addition, the ESRO's drafting group – consisting of representatives of the Ministries of Health, Agriculture and Finance – provided a forum for bargaining, and the 2002 Decision on Rural Health Reform reportedly went through thirty drafts over nine months.Footnote 48 Although we do not have details of the drafting group's negotiations, the Ministry of Finance will have been involved in setting the level of fiscal support for the programme. This support was obtained (on 9 October 2002 at a State Council meeting chaired by Zhu RongjiFootnote 49), but the relatively low per capita fiscal spending on the programme will have been determined in this process.Footnote 50
At the same time, however, the RCMS and NRCMS case shows the limits of bureaucratic bargaining explanations. First, the Ministry of Health developed RCMS (involving villager contributions) at the same time as the Ministry of Agriculture developed its rural tax-for-fee reform policies that sought to eliminate non-tax “fees” (that would include RCMS contributions) on rural dwellers.Footnote 51 As mentioned above, a Decision to tackle fees was approved at the very top of the Party-state in December 1996,Footnote 52 and the RCMS Decision followed in January 1997. Here we see evidence of fragmentation – with different ministries pursuing conflicting policies separately. But instead of disagreements between ministries being pushed upward for mediation and resolution during policy formulation as predicted in the fragmented authoritarian model, initially at least, the Party Central Committee and State Council adopted both policies. It was only later that the Party-state centre issued a decision prioritizing the reduction of farmers’ burdens and forbidding governments to charge (non-tax) fees in the name of the collective, thus undermining RCMS.Footnote 53
Second, the making and adoption of RCMS – and ultimately NRCMS – policy was not noticeably diffuse (in the sense that a particularly large number of bureaucratic actors was involved), though it was protracted, incremental and disjointed. Following a decision to pursue RCMS in 1991, it evolved slowly and incrementally over the next 17 years: the Ministry led experiments from 1993–95, reviewed them in 1996 and the Party Central Committee and State Council issued a decision in 1997 that set a target date of 2000 for nationwide implementation.Footnote 54 RCMS then dropped off the policy agenda until 2001. (The 1998–2001 hiatus could be seen as a “disjointed” period.) It (now NRCMS) was then pursued again at an accelerated pace, with further experiments and ever-wider implementation until it had been adopted nationwide by 2008.Footnote 55
International Influences
As we can see from the account above, a critical juncture in the making of NRCMS policy occurred in 2001–02, when the Party-state decided again to adopt rural cooperative medical schemes. This shift was surprising given the neglect of RCMS since 1997, and even more so since the “new” version for the first time included governmental funding alongside voluntary villager contributions, with central government funding poor areas, and wealthier local governments funding their own.
What caused (N)RCMS to rise up the agenda in 2001 and be adopted as policy in 2002? As we have seen, neither leadership factional politics, rational policymaking nor bureaucratic bargaining have been able explain the policy shift at this time. There was no leadership change in 2001 or early 2002. Leaders had known about rural impoverishment due to ill health and high medical expenses since the mid-1990s, and the central government's fiscal situation had been improving for several years. A key point of intra-bureaucratic contention between the Ministry of Health and the Ministry of Agriculture over contributions and the farmers’ burden remained.Footnote 56 Nor were bureaucratic actors influenced primarily by domestic policy entrepreneurs – the officials, the media or domestic NGOs identified in other policy arenas.
I argue below that to explain the 2002 decision to adopt NRCMS, we need to recognize the important part played by international influences. This includes international organizations, which brought resources and ideas to policy networks they shared with domestic bureaucratic actors and researchers. It also includes international events, which were interpreted in ways that led domestic policy actors to adjust their overall development strategy and the place of RCMS within it. Individual top leaders, accepting these ideas, played a role in pushing or supporting the policy at key moments, in turn because it fitted (or was presented to them as fitting) their overarching, evolving political and economic strategy.
International organizations and policy networks in China
China signed a memorandum of understanding with the World Health Organization in 1978 and joined the World Bank in 1980. From that time, the Ministry of Health engaged extensively with these two international multilateral institutions as well as having bilateral cooperation in the health arena with both governmental agencies and international non-governmental organizations. Wide-ranging activities – including research projects, training courses, lectures and seminars – brought many international health experts to China, and foreign study trips took Chinese officials abroad.Footnote 57
In relation specifically to rural health risk protection, the Ministry of Health partnered with a number of international organizations who funded experiments with rural insurance in the 1980s and then RCMS in the 1990s. From 1985 through to 1993 the Ministry worked together with the Rand Corporation in two counties in Sichuan province to explore rural health insurance options.Footnote 58 This followed a World Bank mission in January 1985 aimed at planning a health loan to China, and at a time when the collapse of Mao-era RCMS was becoming apparent.Footnote 59 The Rand project was included in a World Bank loan in 1986 to experiment with different rural health insurance plans between 1989 and 1990.Footnote 60
In the 1990s, after receiving a top-level steer toward CMS rather than commercial insurance under Li Peng,Footnote 61 the Ministry of Health further explored RCMS policy options in tandem with the World Health Organization (WHO), the World Bank, the United Kingdom government's Department for International Development (DfID), the Rockefeller Foundation, the United Nations International Children's Emergency Fund (UNICEF), United Nations Development Programme and the Asian Development Bank (ADB).Footnote 62 From 1993, for example, a seven-year UNICEF project examined options for financing health care for the rural poor, while the World Bank's 1998–2007 Health VIII project included rural health financing.Footnote 63 In 2001, a reportedly influential ADB project for the State Development and Planning Commission (SDPC) drew on the UNICEF project findings.Footnote 64 Some of these projects contributed to the regulatory framework of NRCMS as adopted from 2002.Footnote 65 It is important to note, however, that alongside these foreign-funded projects were other local experiments that appear to have had no direct international involvement.Footnote 66
This is not to say that international organizations drove policy change. It is difficult to discern whether they encouraged projects on rural health protection or whether the Ministry of Health took the initiative to solicit funding and technical support. Indeed, documented accounts of research projects often indicate that the Ministry of Health and other central government agencies invited support for projects to explore RCMS, insurance or other schemes. Those involved in the World Bank rural health projects in the 1980s for example noted that Ministry officials had “expressed an interest in developing a viable health insurance system.”Footnote 67 And in 1993, the State Council Research Office conducted a study of RCMS that concluded the government should support its revitalization to help solve the problems of access to primary health care and financial risk protection.Footnote 68 In January 2001, the SDPC commissioned the Asian Development Bank to provide technical assistance on possible social security reforms, including rural health insurance, for possible inclusion in the 10th Five Year Plan.
Although they may sometimes have supported different models of rural health financing and service delivery,Footnote 69 international organizations’ willingness to consistently fund projects helped keep rural health protection generally, and often RCMS specifically, on the Ministry of Health and wider central government agenda. The projects that they funded (often via the Ministry's Foreign Loan Office), and to which they contributed technical support, repeatedly helped make the case first that that user-pay rural health care could not provide equitably and there was a need for either RCMS or health insurance. They then argued that RCMS was more viable than commercial insurance, would help reduce ill-health-induced poverty, and that government investment was necessary if RCMS was to provide widespread coverage.Footnote 70 Their reports and the papers that international researchers published often praised Mao-era RCMS and encouraged attempts to reinvigorate or improve on it.Footnote 71
At the same time, these organizations became embedded in Chinese health policy networks and via them into elite personal networks. Their offices in Beijing employed both international and local staff and researchers, and through protracted interactions (including fieldwork, seminars and conferences), their staff and consultants joined a network of actors in the rural health policy arena alongside the Ministry of Health and domestic health researchers. This enabled them to advance and discuss options for delivering health risk protection to rural dwellers and develop arguments about rural impoverishment due to ill health. As an example, the late 1990s UNICEF and 2001 ADB projects involved Ministry of Health researchers and the Harvard School of Public Health, and the ADB report (commissioned by the SDPC and drawing on the UNICEF findings) was sent to the minister of health, Zhang Wenkang 张文康. This minister, who had worked in the past with Jiang Zemin, communicated the report's findings to him personally, with the result that the CCP Central Committee pursued its findings. Liu and Rao link this directly to RCMS moving up the policy agenda in 2001.Footnote 72
China's membership of the WHO and World Trade Organization
International organizations influenced NRCMS policy not only through funding and the ideas they brought to the health policy networks in which they were involved. Here the examples of the WHO and the World Trade Organization (WTO) are instructive. In relation to the WHO, there is evidence that at two points, it (or China's membership of it) encouraged the government to pursue RCMS. First, in 1985 China pledged at the WHO's World Health Assembly to “afford everyone entitlement to basic health care by 2000,” something that would necessitate a move away from the user-pay medical system prevalent at that time and so encouraged the Chinese government to develop rural health risk protection.Footnote 73 In other words, commitments made in this international forum indicate the Chinese government accepting international ideas, benchmarks and targets that may have helped keep RCMS or an alternative on the policy agenda. Second, and more directly, the World Health Organization's World Health Report in 2000 evaluated and ranked health care systems around the world on several different indicators. In terms of “fairness in financial contribution,” China's health care system ranked very low indeed – 188th out of 191 nations – and primarily because of poor health risk protection (insurance-type provisions) in the countryside. Several accounts of RCMS development have indicated that this shocked China's top leaders (not least because RCMS had been praised in the past for its achievements) and catalysed a renewed focus on rural health protection that contributed to the adoption of NRCMS in 2002.Footnote 74
China's membership of another multilateral institution also played a role in the adoption of NRCMS. China joined the WTO in December 2001 after 15 years of negotiations, and its accession was portrayed as a major achievement for Jiang Zemin, who had personally backed it. But the Chinese leadership was aware that WTO entry was likely to hit agriculture (and so farmers) harder than some other sectors of the economy. In August and September 2001, a National People's Congress investigation recommended strengthening rural social security to prepare for WTO accession.Footnote 75 A Party rural work conference held in early January 2002 discussed the likely negative impact of WTO entry on agriculture and the need to mitigate the effects of WTO entry through a series of rural policies, including RCMS.Footnote 76 Immediately after a rural health work conference in late January, Vice-premier Li Lanqing tasked the State Council Office with formulating policy documents (Ministry of Health 2003). Following this, through the rest of 2002, Li pushed forward rural health work in general, and NRCMS in particular.
International events: the Asian Financial Crisis of 1997 and its interpretation
RCMS policy was also influenced by China's regional and international economic integration and particularly by the Asian Financial Crisis of 1997. The Crisis did not directly and immediately affect China's economy, but by 1998 its effects were being felt through harder-hit trading partners in the region. Justin Yifu Lin 林毅夫, a prominent Chinese economist (who had studied in the United States), began to argue that China should seek to grow domestic demand, especially in rural areas, so as to reduce reliance on international markets.Footnote 77 This interpretation then converged with longstanding concerns about low rural incomes and the adverse impact of impending WTO entry. The January 2002 rural work conference neatly drew all these issues together before concluding on the importance of rural work, including rural health work, and the need to implement RCMS:
At present, the most prominent problem in agriculture and rural economic development is still the difficulty of raising rural incomes…. This year is the first year of our country's entry to the World Trade Organization, and agriculture may receive a quite large shock, [so] increasing rural incomes will be even more difficult. Increasing rural incomes not only relates to rural economic development, improving rural livelihoods and rural social stability, but also relates to implementing the line of expanding domestic demand and to the full picture of economic and social development. The whole Party must take this problem very seriously, make increasing rural incomes the most important task in agriculture and rural work, and put in a prominent position in all economic work.Footnote 78
In the 1990s, arguments for CMS had focussed on how it could help tackle rural poverty and well as contribute to rural development and social stability,Footnote 79 but it was not until rural health and poverty were interpreted as holding back wider national economic development that they became a priority. The 19 October 2002 document “Concerning Strengthening Rural Health Work” that announced plans for NRCMS, similarly argued that rural health work “relates to protecting rural production capacity, enlivening the rural economy and protecting social development and stability.”Footnote 80 At the rural health conference held in October 2002 further promoting these rural health policies, including NRCMS, Li Lanqing quoted Jiang Zemin to link rural health work again to the wider goal of economic development:
Comrade Jiang Zemin has pointed out: “Rural health work directly relates to rural development, thriving agriculture and rural health, [and] it relates to the achievement of our country's economic and social development targets.”Footnote 81
Conclusion
Pinning down the factors shaping policies in China is notoriously difficult,Footnote 82 and there is much about the making of NRCMS policy that remains hidden. Despite this, the analysis above has shown that it is not simply the case that Hu Jintao and Wen Jiabao embarked on a new rural social policy agenda after they came to power. NRCMS, widely seen as their first flagship rural policy, was in fact adopted toward the end of the Jiang–Zhu administration in October 2002, while Jiang had supported an earlier variant in 1996. In addition, the commitment to funding it and coordinating its implementation was taken by January 2003, before the SARS epidemic hit the headlines and before Wen Jiabao became premier. This article thus reveals policy continuities across administrations where others have emphasized discontinuities and seen factional differences.Footnote 83
Top leaders have nevertheless evidently played an important role in the adoption and then implementation of NRCMS. Li Peng supported it in 1990–91, and together with Jiang Zemin, backed it in 1996. Vice-premier Li Lanqing pushed it forward in early 2002, perhaps at the behest of Jiang, who is reported to have come out in support again from 2001.Footnote 84 Hu Jintao and Wen Jiabao then supported its implementation after they came to power. But at the same time, the NRCMS case shows that it is not always sufficient for a top leader – even the Party General Secretary – to back a policy. Although Jiang Zemin supported RCMS in 1996, and the CCP Central Committee and State Council Decision in 1997 adopted it, the Party centre then apparently retreated, and prioritized rural tax-for-fee reform instead.
But NRCMS was not simply a rational leadership response to the discovery of a social problem. The problem of lack of RCMS coverage had been recognized by the Ministry of Health in 1985 and by the Party centre and State Council by 1991, but it took until 2002 for NRCMS to become sufficiently prioritized to be adopted and government funded, and until 2008 for it to be implemented nationwide. As we have seen through this study, the top leadership's agenda was in flux as policy ideas mixed and some rose to become prominent issues. NRCMS was adopted and implemented when it appeared to contribute to solving several prominent social, political and economic problems – with problem-definition partly shaped by international events and ideas.Footnote 85
Institutional arrangements encouraged and supported ministries to produce and experiment with policies, but bureaucratic bargaining over resources was not central to NRCMS development. Fragmented authoritarian explanations tend to focus on bargaining, but we see that only in the final months before the adoption of NRCMS. In the 1990s, rather than bargaining, we saw the simultaneous adoption of competing policies by the highest levels of the Party-state and then within a year the Party stepping in to clarify which policy had priority. The result was a failure to implement NRCMS. We do not know exactly what happened behind the scenes at that time, but it appears that the Party centre prioritized tax-for-fee reforms because it was concerned with rural unrest and because as the Asian Financial Crisis hit China it pushed financial probity and fiscal prudence up the agenda, perhaps particularly for Zhu Rongji.Footnote 86 Thus central Party-state priorities apparently changed not only due to learning within policy spheres, but also under the influence of international events and an evolving development paradigm.
This article also shows the important role that international organizations have played in supporting and encouraging NRCMS. They funded research and policy experiments from the mid-1980s through the 21st century that helped establish not only the impact of poor health protection on rural poverty but also RCMS's need for government funding. Nevertheless, learning, research and experimentation was insufficient: there was a huge amount of this from the late 1980s in relation to RCMS right through into the 21st century and yet NRCMS was not adopted until 2002. The ADB/UNICEF research finding about the scale of impoverishment due to ill health may have catalyzed Jiang to push the policy again from 2001. But it also followed the adoption of a view that overall economic development needed stronger domestic demand, the WHO's critical 2000 report and the problems that WTO entry was likely to create for farmers. This combination of factors brought together health and rural economic considerations. The 2003 SARS epidemic then most likely consolidated commitment to implementing the scheme.Footnote 87
International influences on China's social policies were not exercised, as in many developing countries, through “conditionality” – loans tied to certain conditions. Instead, they were the result of a more subtle process involving ideational influence that was mediated by Chinese Party-state agencies and the officials within them.Footnote 88 This goes beyond the impact of socializing influences of multilateral institutions on China's foreign policy decisions and its adoption of international policies and practices.Footnote 89 It indicates that China's post-Mao international integration and participation in international organizations have profoundly influenced domestic policy.Footnote 90 Influential actors within the Chinese Party-state have not only absorbed pro-market economic ideas from outside,Footnote 91 and bought into the GDP growth, consumption-led, globalization model,Footnote 92 they have also accepted social policy ideas, including concepts of social development and health-related equity.
International factors have not yet been incorporated into models of policymaking in China, no doubt due to the difficulties pinning down the influence of ideas as well as the justifiable tendency in analyses of authoritarian political systems to focus on state actors and their power plays. But – even for all their recurring concern about bourgeois liberalization and the potentially negative impacts of “Western” thinking – Chinese Party-state agencies have been keen to search abroad for policy ideas. An examination of these ideas in Chinese policymaking – including how international ideas are introduced and evolve and shape within policy networks in China – is therefore long overdue. At the same time, more research is needed on the mutual influence of ideas introduced by international actors and those of Chinese domestic actors in policy networks – this is after all surely a two-way process. And more research is needed on when and why international ideas are sometimes rejected or taken as negative examples.Footnote 93
Having shown the limitations of existing models of policymaking in China, this article proposes a new one – “Network Authoritarianism.” Rather than limiting itself to leaders or bureaucratic agencies as the key actors in policy change, this model makes space for many different actors, and sees them as interacting in policy (and personal guanxi 关系) networks that allow ideas to be introduced, exchanged and developed. These networks span the state–non-state (civil society) boundary as well as the central–local and national–international divides, and they may overlap.Footnote 94 While state actors still play an important role in formulating policy documents, and in making decisions (the “authoritarian” element of the model), they can nevertheless be subtly, but often fundamentally, influenced by the ideas of other network participants with whom they interact.
As with previous work on policymaking, Network Authoritarianism identifies novel features of a picture containing many actors and their complex interactions.Footnote 95 It seeks not only to highlight new actors but also to characterize better than previous models their interactions. Network Authoritarianism differs from Fragmented Authoritarianism because it emphasizes not the institutions that divide and segment bureaucratic actors (though of course these exist), but the informal as well as formal networks that form bonds between them. It differs from “FA 2.0” because it sees actors (international as well as domestic) outside the state bureaucracy not as simply finding spaces in the interstices of a fragmented polity, but as sometimes influential constituents of policy networks.Footnote 96 It also differs from “Consultative Authoritarianism,” with its focus on the Party-state's domination of the policy process and its creation of channels to solicit policy feedback, because it sees Party-state actors as subject to influence – sometimes over the definition and identification of problems as well as over policy solutions.Footnote 97
The Network Authoritarian model of policymaking in China has been developed from research on only one social policy. The extent of international (as well as domestic civil society) participation and influence in policy networks will vary between policies and policy areas, but is unlikely to be confined to this policy alone. Whether – or to what extent – the interaction with international actors in social policy extends to other domestic policies, awaits further study. But clearly many of the international actors referred to in this article – the World Bank and UNICEF, for example – have been active in China not only in this policy arena, but also in many others.
Finally, we need also to pay attention to changes in Chinese policymaking over time. Fragmented Authoritarianism refocussed attention on bureaucratic actors at a time – the early post-Mao era – when individual leaders’ power was a little less evident, the state bureaucracy had been rebuilt after the Cultural Revolution, and China's international engagement beyond the Communist block had only just begun. This article examines most closely the period just after that, from the 1990s through to 2002. It is possible therefore that it does not uncover factors neglected by earlier work but instead reveals changes to policymaking that took place in the 1990s. The turn of the 21st century, when China joined the WTO, was a key moment in China's deepening involvement in the international economy and world order. Jiang Zemin had made it a personal goal to secure China's entry as a defining achievement of his administration and so its influence was likely to be particularly strong at that point. China's economic integration has deepened significantly since the early 2000s and so international influence is likely to have continued to shape policymaking. But Xi Jinping has become more personally powerful in a range of policy areas, and there has been since 2015 push-back against the influence of “Western” ideas in some spheres. We thus need to ask whether (and how) international influences on policymaking in China will grow or decline in the coming decades.
Acknowledgement
Research for this article was supported by the Economic and Social Research Council (ES/J012629/1 and ES/J012688/1). The author would like to thank Wang Guohui, Jude Howell, Victor Shih and two anonymous referees for their very helpful comments and suggestions.
Biographical note
Jane DUCKETT is Edward Caird Chair of Politics at the University of Glasgow and Director of the Scottish Centre for China Research.
Appendix: Timeline of (N)RCMS Policy Decisions
1985 Health protection for all (WHO), and experiments in rural health insurance with Rand and World Bank.
1997 Party-state Decision on RCMS (not implemented).
2002 Decision on ‘new’ RCMS.
2005 Decision to implement NRCMS nationwide.
