Establishing Appropriate Agency Relationships for Providers in China

Liu, Yu; Saltman, Richard B.

There has been concern in the past that the rise of China's promarket health care delivery system between 1978 and 2002 had sown the seed for a major public health breakout, SARS (Severe Acute Respiratory Syndrome), in 2003 in China. 20 The SARS epidemic combined with other health services issues, for example, increasing out-of-pocket health care expenditures and insurmountable access barriers to health care (in a popular Chinese proverb: kanbingnan, kanbinggui), led to a comprehensive health care reform in 2008. 20 Although some researchers may not completely agree, 21 by 2012, this Chinese health care reform has achieved significant progress toward the first 4 goals set in 2008, including expanding social insurance coverage and public health services, improving the primary care delivery system, and establishing an essential medicines system. 20 However, by 2012, the pilot public hospital reforms in 17 cities had failed to deliver meaningful results, 20 and the progress of public hospital reforms had been slow. 6 Currently, public hospital reform remains one of the major issues on the Chinese health care reform agenda. The number of public hospital reform piloting cities expanded to 100 in 2015, and all the city-level public hospitals and hospitals above this grade were expected to be undergoing reform by 2017. 22 The Chinese government believed that health care reform had already entered the "deep water zone" in that public hospital reform was the most difficult component. 23 In the Chinese State Council's "The Thirteenth Five-Year Plan for Deepening Healthcare System Reform," the government listed several aspects of public hospital reform as one of the most important tasks. 24 In addition to the general public hospital reform challenges shared with other countries (eg, the 3 structural sources and the 3 contextual sources summarized by Edwards and Saltman), 25 China's current public hospital reform confronts several unique challenges. Among these unique challenges is the lack of appropriate and clear physician agency relations caused by the combination of the dominating role of tertiary-level public hospitals, public hospitals' profitdriven behaviors, the existing strong financial ties between physicians and public hospitals, and the lack of a comprehensive physician professionalism system.