Reasons behind stymied public hospital governance reform in China

Background The public hospital governance reform in China is pledged to improve the governance of public hospitals and deliver affordable and high-quality care. However, progress in public hospital reform has been slow. The reason is poorly understood. Methods A research center affiliated with China National Health Commission has conducted 32 workshops to interview 124 public hospital administrators from 30 provincial-level administrative divisions and 105 various-level government officials from three provinces. About 80% of administrators and 78% officials actively participated the discussions. We used a descriptive theoretical approach to understand the relationships between the governance reform and characteristics of its stakeholders. We also analyzed stakeholder interests and their power to influence the reform. Findings About 66% of hospital administrators, 72% of health officials, and less than 10% of other officials support a new hospital governing structure. Local leadership, hospital administrators, and health commission said that administrators should have more power over the management of public hospitals. Other government departments and healthcare professionals had reservations on the governance reform. The reform of public hospital governance faces significant obstacles. The interests of most government stakeholders are not aligned with public interests. All stakeholders perceived that their workload would increase in the short term because of the governance reform of public hospitals. Most people involved in the reform are not incentivized to collaborate. The health commission has limited financial resources and insufficient political power to implement a massive reform. Most importantly, the public hospital reform is not, and likely will not be, a top policy priority to the central government or local leaderships. Interpretation The health commission needs more political support and resources to speed up the public hospital reform. To fulfill the pledge of affordable, equitable access to quality care, Chinese government needs to overcome significant obstacles in the public hospital reform.


Methods
A research center affiliated with China National Health Commission has conducted 32 workshops to interview 124 public hospital administrators from 30 provincial-level administrative divisions and 105 various-level government officials from three provinces. About 80% of administrators and 78% officials actively participated the discussions. We used a descriptive theoretical approach to understand the relationships between the governance reform and characteristics of its stakeholders. We also analyzed stakeholder interests and their power to influence the reform.

Findings
About 66% of hospital administrators, 72% of health officials, and less than 10% of other officials support a new hospital governing structure. Local leadership, hospital administrators, and health commission said that administrators should have more power over the management of public hospitals. Other government departments and healthcare professionals had reservations on the governance reform. The reform of public hospital governance faces significant obstacles. The interests of most government stakeholders are not aligned with public interests. All stakeholders perceived that their workload would increase in the short term because of the governance reform of public hospitals. Most people involved in the reform are not incentivized to collaborate. The health commission has limited financial resources and insufficient political power to implement a massive reform. Most importantly, the public hospital reform is not, and likely will not be, a top policy priority to the central government or local leaderships. PLOS

Introduction
The recent healthcare reform in China aims to expand health insurance coverage, equalize public health services, strengthen primary care, establish essential medicines program, and reform public hospitals [1]. Most of the researchers agree that the social health insurance system is the most successful policy pillar in the reform [1][2][3]. Recently, a new State Medical Insurance Administration has been established to consolidate health insurance schemes [3]. In contrast to the success of the health insurance expansion, progress in healthcare delivery reform has been slow, especially with the public hospital-centered system [1]. The State Council issued the newest round of policies to improve public hospital governance structure in 2015. The reform emphasizes separation of government control and hospital management [1,2,4,5]. There are many challenges in implementing the separation of ownership from operation. In this study, the project team from a research center of China National Health Commission met with public hospital administrators from 30 provincial-level administrative divisions and various stakeholder government agencies at three provinces. We analyzed the power of stakeholders and their attitudes towards reform and briefly discussed how the public hospital-centered service delivery system would perform.
The healthcare system in China serves a fifth of the world's population. Between 1960 and 2018, life expectancy rose from 43 to 76 years; most of this increase can be attributed to economic growth and improvements in public health [2,6]. However, China's current healthcare system faces fresh challenges in delivering affordable and high-quality care to meet the growing needs and rising expectations of Chinese people [1]. Unlike the health system in the 1960s and 1970s, the service delivery system after the China Economic Reform highlights the role of acute care and hospitals [7]. Although the system is extremely public-hospital-centered, it is often profit-driven [1]. Public hospitals had 89% of total hospital beds and delivered 92% of outpatient visits [8]. In 2016, 78% of China's total healthcare expenditure occurred in the hospital sector, as opposed to the 29%-to-42% seen in other countries (Japan 40%, Canada-29%, UK-42%, US-34%) [9]. Because the government set fixed low rates for services and room and board [10], public hospitals were often motivated to maximize profits and use profits to subsidize staff salaries [8].
There were many attempts to improve the public hospital system, but two landmark reforms stand out. A reform in the 1980s introduced market incentives to public hospitals, just like those offered to other sectors in the economy [1]. The number of hospitals in China has more than doubled between 1980 and 2010 [8], and 30% to 40% of hospital revenues were generated by out-of-pocket payments. A more recent reform aims to improve the governance of public hospitals so the public healthcare delivery system can provide affordable, equitable access to healthcare services.
The separation of ownership and operation or guanban fenkai is one of the core guidelines for the public hospital reform. In contrast to private hospitals in China or public hospitals in the USA and Europe, the ownership status and legal structure of China's public hospitals are less clear. Many government branches at different levels are involved in personnel management, financing hospital services, and infrastructure investment decisions [10]. For example, hospital assets are owned by one or more government departments, and hospital administrators have little autonomy in managing their staffing [11]. The lack of separation between ownership and management means that China's public hospitals are sometimes bureaucratic in culture, structure, and function [2,10].
There are various forms of separation reforms in theory and in practice [2,5,8,12]. The progress of the reform has been slow to date [1,2,8]. To our knowledge, no study has examined why the public hospital reform lacks progress towards improvements in the governance of public hospitals and affordable and high-quality care. This is the first comprehensive study to date examining the reasons behind stymied public hospital governance reform in China. In addition, this study contributes to the literature in two other aspects. First, it gives a voice to public hospital administrators and government stakeholders expressing their concerns and feelings and ensures that study findings of separation reform are grounded in their experiences. Second, it explores the changing power and position of stakeholder groups during the reform.

Materials and methods
In early 2016, a research center of China National Health Commission was instructed to study the progress and challenges in implementing the public hospital governance reform. The leadership of China National Health Commission wanted to collect opinions and feedback from public hospital administrators and government stakeholders. A total of 32 workshops were carried out at various locations ( Table 1). The project team are independent qualitative researchers from the research center and a prestigious university, not affiliated with any stakeholder groups. They have received government funding to organize the workshop meetings. They purposively selected participants from different stakeholder groups and also from various administrative hierarchy levels [10,13]. The research questions in this manuscript were embedded in meetings which lasted for 1.5 to 3 hours. Because invited hospitals and stakeholders received direct orders (meeting announcements) from their upper level government, refusals to participate was not an issue in this study. The ethics committee of Peking University waived the need for ethical approval. The need for consent was waived by the ethics committee of Peking University.
The participants included 124 hospital administrators (presidents or party secretaries), 25 health officials, and 80 government officials from other departments (Offices of local leadership, Development and Reform Commission, Finance, Human Resource and Social Security, Organization Department of Chinese Communist Party, Bureau of Price Supervision, Office of Staffing). The order, time, and participants of these workshops are listed in Table 1. During the first phase, five workshops were conducted with 79 administrators of general or specialty public hospitals from 30 provinces, autonomous regions, and municipalities. For the second phase, researchers visited three provinces and organized workshops at local governments of three levels (province, city, and county). We organized three workshops at each local government with different stakeholder groups. The workshops with health officials were carried out before the meetings with hospital administrators and other government officials.
We used a descriptive theoretical approach to understand the relationships between the governance reform and its stakeholders [14]. Audio-recording was not used, to facilitate participants involvement in the workshop and stimulate discussions. All participants were stakeholders to the public hospital reform [10], which enhanced the quality and credibility of both the workshop and its results [14]. The facilitator had extensive experience in designing and facilitating workshops with stakeholders in the healthcare system. The facilitator ensured that the group did not deviate from the semi-structured agenda. The shy and quiet participants in the group were protected and encouraged to speak out. Two researchers took notes. Also, notes were confirmed through the feedback process at the end of the workshop. After the workshops, we conducted follow-up one-on-one interviews with "typical participants" and participants with unusual viewpoints or experiences to expand the coverage of the research topic [15]. The process of the workshop can be seen in Table 2.
Hospital administrators were sent five questions in the invitation mail.   We first asked whether they support creating a new organization that merges ownership-related administrative functions. Then we used those questions in the invitation letter for the general group discussions.
For the second half of the discussions, the facilitator used specific probes to fully elicit participants' views on the power and positions of stakeholders in the governance reform. Those participants spoken at least twice in the discussions were defined as active participants in this study.
Although the most common analyses of workshop results involve a transcript of the discussion, we were not able to transcribe the discussion because audio-recording was not used. Instead, we used a qualitative content analysis to examine the researchers' notes. The analysis focused on extracting themes from the notes, with a deductive approach [16]. One researcher read through the notes several times and created a pilot list of prior themes. The notes were then coded according to these themes. If relevant notes could not be coded into an existing theme, a new theme was created. During the coding process, sub-themes were also created, or existing themes were merged. The coding and analysis results were discussed with a second researcher to improve the extraction of the information and the reliability of the results. Based on the results from 32 workshops, we analyzed the administrative authority, workload, and positions of stakeholders and briefly discussed how the healthcare system would perform.

Results
A total of 229 hospital administrators and government officials participated in the study. Among them, 33, 31, and 41 officials serve at provincial, city, and county level governments, respectively. The hospital administrators had an average age of 51.0 (95% CI: 43.9-58.1), and over 80% of them (95% CI: 71.8%-88.2%) had post-graduate education. Ten stakeholder groups were considered core influential groups, including local leadership (offices of Party Secretary and Government Leader, e.g. party secretary and governor of a province), Department of Finance, Health Commission, Human Resource and Social Security, Development and Reform Commission, Bureau of Price Supervision, Organization Department of Chinese Communist Party, medical colleges, healthcare professionals, and administrators in public hospitals. They possessed two or three of the following stakeholder attributes: (1) power to influence the reform, (2) the legitimacy of the stakeholder's relationship with the reform, and (3) the urgency of the stakeholder's claim on the reform [13]. About 80% of hospital administrators (99 out of 124) and 78% officials (82 out of 105) actively participated the discussions. Officials with high ranks were more active than lower-ranking ones (84.2% or 64 out of 76 vs 51.7% or 15 out of 29, p<0.01). The public hospital reform has made little progress to separate ownership and administration. About 66% of hospital administrators, 72% of health officials, and less than 10% of other officials support creating a new organization that merges hospital-ownership-related administrative functions. Table 3 lists the theme categories that emerged from the workshops: society's expectations, tasks or role in the governance reform, potential changes of administrative authority and workload, and stakeholder objectives. In addition, some participants discussed their personal objectives or incentives, which will be described below. We found that all stakeholders perceived that their workload would increase in the short term because of the governance reform of public hospitals. There is quite a distance between society's expectations and stakeholder objectives.
We found that stakeholders can be regrouped into two large categories by their attitudes towards the public hospital reform. Local leadership, hospital administrators, and health commission said that administrators should have more power over the management of public hospitals. Other government departments and healthcare professionals hesitate on the governance reform.
Although local leadership, the health commission, and hospital administrators have similar attitudes towards the reform, they have quite different objectives and power to influence the reform ( Table 3). The local leadership wants to maintain the social welfare nature of public hospitals and alleviate the problem of kanbinnan (healthcare is too inaccessible) and kanbingui (healthcare is too expensive), without significantly affecting the political stability and interests of stakeholders. The local leadership has the greatest power to influence the reform, but the governance reform of public hospitals is not a policy agenda item of top priority and/or urgency (quote 1).

Quote 1 (local leadership)
: "Whether in the government annual report or in the city development plan, there is less than half a page on healthcare, and it is political rhetoric without details, the public hospital governance reform may have to give way to other more critical issues. . ." The health commission supports the governance reform because they felt that they were often wrongly criticized by the media and the general public for all of the problems in healthcare, such as kanbinnan, kanbingui, violence in hospitals, and homemade cancer drugs. They want to change their image through a reform. They aim to draw a line between the health commission and public hospitals and help society understand the complexity of healthcare and the commission's difficulties regarding limited resources and political power (quotes 2-5).

Reduced Increased
The workload is not increased by the reform of public hospitals, and retain administrative authority over public hospitals.

Pricing
Stabilize and standardize appropriate medical service prices, alleviate the problem of "kanbingui"; and actively cooperate with the reform of public hospitals.
Re-adjust the price of medical services, or completely transfer pricing to public hospitals Reduced Increased Administrative authority is still maintained over public hospitals without increasing the difficulty of work and the workload.
Org Dep Assist in promoting the reform of the legal status of public hospitals, personnel management, and multisite practice; Talent activation in healthcare; supervise the health workforce The hospital administrators have high expectations for the public hospital reform, as the current system has long suppressed its enthusiasm for innovation and significantly constrained its business intellect. At the same time, they felt the reform lacks operability. They are not fully convinced that the management-related administrative power will be transferred to the administration team (quote 6), as the local leadership and health commission still question the administrator team's motivation for social welfare. The administrators also felt uncertain about how the reform will affect their cadre ranking in the political system (quote 7). Other government departments are concerned about increased workload in the short term and reduced administrative authority over public hospitals in the long term (Table 3). They are reluctant to collaborate with the health commission and public hospitals to make changes and transfer certain authorities to administrators (quotes [8][9][10][11].  Healthcare providers have little power to influence the reform. They worry that they may lose their tenure status in the political system after the reform. Moreover, they are uncertain about how the reform will affect their income, career development, and work-life balance.

Discussions
Hospital administrators, healthcare professionals, and eight government branches were the core influential groups in the public hospital reform. Local government leadership, health commission, and hospital administrators were generally supportive of the governance reform of public hospitals. Other stakeholders hesitate on the reform. The supporters have quite different objectives and power to influence the reform. The public hospital reform is not a top priority to the local leadership although they have the greatest power to influence the reform. The health commission does not have the power and resources to strong-arm other government departments. Although the hospital administrators want more management autonomy from the government, they have little power to influence the reform, and they felt the reform lacks operability. Other government departments were unanimously reluctant to collaborate with the health commission to transfer certain authorities to hospital administrators.
The governance reform of public hospitals has four significant obstacles to overcome. First, the interests of most government stakeholders are not aligned with the public interest, which was observed in other socio-economic reforms in China [17][18][19]. Second, the uncertainties from the public hospital reform have potential negative impacts on the interests of personnel working for government stakeholders and hospitals. People involved in the reform were concerned about the increased workload in the short term and trade-offs they will face. These two obstacles can be overcome through strong leadership and a dedicated team, similar to what has happened in environmental protection in recent years [20,21]. However, the health commission is not able to push this massive reform effort through because they have limited financial resources and political power. Lastly, and ultimately most importantly, the central government and local leaderships did not make public hospital reform a top policy priority.
The public hospital reform has "to give way to other more critical issues." Although China's per capita nominal GDP ranked 71st among 184 economies, the Chinese government can accomplish challenging tasks through concentrating on important goals (jizhong liliang bandashi). For example, China has used performance evaluation as a hands-off strategy to secure top-down control and meet priority targets [22], such as family planning and economic growth. Since 2009, local governments at or beyond county level have been evaluated in five areas including political/ideology work, leadership capacity, work performance, integrity and anti-corruption, and accomplishing major goals [22]. Work performance is measured by economic development, social development, and many other aspects. Healthcare is lumped into social development. The 2017 Communist Party Congress announced three major goals or "critical battles," namely financial risk mitigation, poverty reduction, and environmental protection. Therefore, the health commission will need the new fuel in the future to speed up the public hospital reform [23].
This study has several limitations. All the participants were recruited from the bureaucracy hierarchy. They are not volunteers, but they may still have some characteristics in common. We were not able to interview healthcare administrators in the private sector. More themes may be discovered if we can involve the private healthcare companies. We were not able to audio-record the workshops, which is a typical practice in projects initiated by the Chinese government. Using audio-recording is an obstacle for participants to express their opinions openly. Instead, researchers took extensive notes in the workshops.

Conclusions
Progress in public hospital reform has been slow. The governance reform of public hospitals faces significant obstacles. The interests of most government stakeholders are not aligned with public interests. Most stakeholders involved in the reform are not incentivized to collaborate with each other. The health commission at difference level of governments has insufficient political power and limited financial resources to carry out a massive reform. Most importantly, the public hospital reform is not a top policy priority to the central government or local leaderships. The participants were concerns that the health commission had the political support and resources to speed up the public hospital reform. To fulfill the pledge of affordable, equitable access to quality care, Chinese government needs to overcome these significant obstacles in the public hospital reform and provide the health commission more support and resources.