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We shall experiment, but how shall we learn?: Next steps for research on innovation in China’s health and social policy

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We shall experiment, but how shall we learn?: Next steps for research on innovation in China’s health and social policy

Future Health Systems

By Lewis Husain and Gerald Bloom, FHS researchers

Some years ago, Tony Saich likened doing research on local government in China to the story of the blind men and the elephant – the complexity of China, and the differences between places, mean that different people experience different things, and describe different realities.

China has always provided avenues for interesting research. Many of the debates that Tony Saich was reflecting on were around China’s rapid industrialisation, development of markets, and the ways in which local governments steered reforms. Fifteen years on, while the debates have progressed and the amount of research and analysis on China has increased dramatically, some of the fundamental questions remain.

FHS partner the Institute of Development Studies (IDS) has been working with partners at the Institute of Sociology at the Chinese Academy of Social Sciences and at the China National Health Development Research Centre (CNHDRC) (also an FHS partner) over a number of years. A fundamental focus has been the importance of policy process in China’s reforms and development. This includes the management of sub-national innovation and system-level learning in social sector reforms in China, primarily in healthcare.

This work builds on a tradition of research on sub-national policy in China which goes back a long way, and on more recent analyses of local government innovation. It also links clearly to current agendas in the reform of the Chinese healthcare system, where there is a need for deepened reform if China is to avoid the risk of creating a ‘high-cost, low-value’ healthcare system as growth slows and need (and demand) continues to increase. As a recent report by the Chinese government, World Bank and WHO noted, such a transformation of the health system will require stronger systems for accountability and learning – M&E, oversight and feedback systems – that can underpin the next stages of reform in a system that is increasingly complex and hard to navigate. As Dani Rodrik framed the dilemma: “We shall experiment, but how shall we learn?”

Our research also speaks to a question which is becoming ever more pertinent as China’s engagement in overseas development increases – what can the rest of the world learn from China? Clearly, there’s no shortage of discussion – or appetite – to look towards China for lessons in healthcare and social sector reforms. The IDS Rising Powers in Development programme reflects this changing dynamic. But how can we think about learning between contexts, when so much of China’s developmental ‘experience’ seems to operate more at a system or process level, than at the level of discrete best practices that can be summarised and easily learnt from?

These questions are becoming more prominent as China’s development cooperation moves forward, with the establishment of the State International Development Cooperation Agency and funding vehicles to support overseas engagement by Chinese agencies. How do Chinese agencies, tasked with building international collaborations and ‘doing development’, conceive of their role? What presuppositions do they bring regarding China’s developmental experience and how that can be adapted to other contexts? How can established development agencies work with Chinese counterparts to support this process and help maximise their contribution, while minimising risks?

Two recent papers in Globalisation and Health speak directly to these issues.

A paper by Lewis Husain examines processes of local governments’ management of health reforms in response to major national policies. It shows ways in which sub-national practices help fill in the gaps in national policies, and how they can contribute to system-level reforms. It argues that a lot of what we see in China, while imperfect, is similar to many quite ‘organic’ approaches now being discussed in the development studies community for management of reforms in complex systems – systems with lots of moving parts, which are hard to understand, and where it’s hard to predict outcomes. This points to the importance of looking at process and learning, rather than discrete best practices, when thinking about learning from China’s health and social welfare reforms.

A second paper, by Xiao Yue, Lewis Husain and Gerald Bloom, looks at how the role of a key government research institute, the CNHDRC, is changing as the need for higher quality evidence to guide health reforms increases. The paper shows the challenges in trying to assess and provide useful feedback on the progress of reforms in a system as heterogeneous and complex as China’s. It discusses how agencies such as the CNHDRC are experimenting with methods used by the development M&E community, including realist evaluation and utilisation-focused evaluation, in a search for ways to better analyse sub-national reforms and provide feedback to decision makers. These explorations with new approaches are ongoing, but are steps towards greater methodological rigour in dealing with complex reforms and, hopefully, better system-level stewardship of the kind highlighted above.

Overall, this is an exciting agenda. Despite the recent increase in attention to government innovation in China’s reforms, there remains a lot we don’t understand well, and a lot of space for work both on how ‘traditional’ Chinese repertoires are being retooled for a new era and changing demands, and on how this is playing out internationally and the implications for global development.


Lewis Husain and Gerry Bloom are engaged in the evaluation of the China-UK Global Health Support Programme, funded by the UK Department for International Development. Read their recent briefing on China’s changing global health commitments.


Image credit: AddisWang, Creative Commons license 3.0