xviii DEEPENING HEALTH REFORM IN CHINA conceptualized to be interlocked and are not care and leaders in workforce development. designed to be implemented as independent Measurement,monitoring and feedback are actions.For example,actions taken by front based on up-to-date,easily available,and line health care providers will require strong validated data on the care,outcomes,and institutional support combined with finan- behaviors of providers and patients. cial and human resource reforms in order to achieve the reform goals. Second,continuous quality improvement is a foundational element of PCIC and creat- At the core of the recommendations is the ing a high value system,and is essential for full adoption of a reformed service deliv- gaining citizen trust.Government leadership ery model,referred to as people-centered and stewardship are vital for building capac- integrated care(PCIC),in order to acceler- ity to improve quality of health care.The first ate progress toward China's vision of bealth priority is to have a full service coordination service delivery reform and improve value architecture to oversee systematic improve- for money.PCIC is the term used to refer ments to health sector quality throughout to a care delivery model that is organized the service delivery system,including public around the health needs of individuals and and private sectors.This architecture would families.The bedrock of a high-performing be publicly responsible for coordinating PCIC model is a strong primary care system all efforts aimed at quality assurance and that is integrated with secondary and tertiary improvement,including linking service qual- care through formal linkages,good data,and ity with the incentives applied by the service information sharing among providers and purchasers,and would actively engage all between providers and patients,and active stakeholders to facilitate the implementation engagement of patients in their care.It uti- of quality assurance and improvement strat- lizes multidisciplinary teams of providers that egies.Stakeholder organizations,including track patients with eHealth tools,measures NHFPC,MOF,MOHRSS,and key profes- outcomes over the continuum of care and sional and scientific bodies,would be repre- relentlessly focuses on continually improving sented.Operationally,at current stage,China quality.Curative and preventive services are may consider to have State Council Health integrated to provide a comprehensive experi- Reform Leading Group to take this func- ence for patients,and measurable targets for tions to ensure the highest level leadership facilities.Large secondary and tertiary hos- and authority to mobilize public and private pitals have new roles as providers of complex stakeholders and citizen engagement.New FIGURE ES.1 8-in-1 Interlinked Reform Levers Service Delivery System Tiered health care delivery system in accordance with People Centered Integrated Care Model (PCIC) Rebalanced and Value-based Reforming Public Health Service mprove Quality of Care Hospitals and Improving Engaging Citizens in Delivery in Support of PCIC their Performance Support of the PCIC 8-in-1 Reform Institutional and Financial Environment Levers Realign Incentives Stengthening Health in Purchasing and ·Better Health Provider Payment Workforce for PCIC ·Higher Quality and Modemizing Health Patient Satisfaction Strengthen Private Service Planning Affordable Costs Sector Engagement to Guide Investment
xviii DEEPENING HEALTH REFORM IN CHINA conceptualized to be interlocked and are not designed to be implemented as independent actions. For example, actions taken by front line health care providers will require strong institutional support combined with financial and human resource reforms in order to achieve the reform goals. At the core of the recommendations is the full adoption of a reformed service delivery model, referred to as people-centered integrated care (PCIC), in order to accelerate progress toward China’s vision of health service delivery reform and improve value for money. PCIC is the term used to refer to a care delivery model that is organized around the health needs of individuals and families. The bedrock of a high-performing PCIC model is a strong primary care system that is integrated with secondary and tertiary care through formal linkages, good data, and information sharing among providers and between providers and patients, and active engagement of patients in their care. It utilizes multidisciplinary teams of providers that track patients with eHealth tools, measures outcomes over the continuum of care and relentlessly focuses on continually improving quality. Curative and preventive services are integrated to provide a comprehensive experience for patients, and measurable targets for facilities. Large secondary and tertiary hospitals have new roles as providers of complex care and leaders in workforce development. Measurement, monitoring and feedback are based on up-to-date, easily available, and validated data on the care, outcomes, and behaviors of providers and patients. Second, continuous quality improvement is a foundational element of PCIC and creating a high value system, and is essential for gaining citizen trust. Government leadership and stewardship are vital for building capacity to improve quality of health care. The first priority is to have a full service coordination architecture to oversee systematic improvements to health sector quality throughout the service delivery system, including public and private sectors. This architecture would be publicly responsible for coordinating all efforts aimed at quality assurance and improvement, including linking service quality with the incentives applied by the service purchasers, and would actively engage all stakeholders to facilitate the implementation of quality assurance and improvement strategies. Stakeholder organizations, including NHFPC, MOF, MOHRSS, and key professional and scientific bodies, would be represented. Operationally, at current stage, China may consider to have State Council Health Reform Leading Group to take this functions to ensure the highest level leadership and authority to mobilize public and private stakeholders and citizen engagement. New FIGURE ES.1 8-in-1 Interlinked Reform Levers Modernizing Health Service Planning to Guide Investment Strengthen Private Sector Engagement Improve Quality of Care in Support of PCIC Realign Incentives in Purchasing and Provider Payment Institutional and Financial Environment Service Delivery System Engaging Citizens in Support of the PCIC Stengthening Health Workforce for PCIC Reforming Public Hospitals and Improving their Performance Tiered health care delivery system in accordance with People Centered Integrated Care Model (PCIC) “8-in-1” Reform Levers Rebalanced and Value-based Health Service Delivery • Better Health • Higher Quality and Patient Satisfaction • Affordable Costs
EXECUTIVE SUMMARY xix national agencies dealing with the area of for all services.Rather,they are increasingly quality have been created in number of coun- becoming part of a network of facilities that tries,including Australia,England,France includes other providers such as primary and the United States.Whatever the option, care,diagnostic units and social services this entity would serve as the ultimate source They are steadily shifting low complexity of scientific information on all quality-related care to lower levels,and sharing personnel topics for both clinicians and the public.It and providing technical assistance and train- will also become the institutional leader in ing to them.Moving public hospitals to their promoting quality of care and ensuring that new roles in China will require strengthen- evidence-based care is consistently delivered ing accountabilities and improving manage- at the highest standard.This entity could ment.Reform will entail enacting a legal also serve as a platform for tapping interna- framework that specifies organizational tional experience in care improvement.Many forms(such as boards or councils)that serve OECD countries have established such insti- as the accountable interface between govern- tutions.Commitment to improving quality ment and hospital management,setting the of care can be further enhanced by conduct- roles,composition and functions of these ing an in-depth national study of the state of boards or councils,granting decision-making quality of care and quality improvement ini- autonomy to the same,and putting in place tiatives at all levels of the system.In a number robust accountability mechanisms and incen- of countries,efforts to improve health system tives that align hospital performance and performance are catalyzed by comprehensive, behaviors with government priorities and data-based reports on quality and perfor- the reformed delivery model.China would mance.These reports helped focus the atten- also benefit from professionalizing hospital tion of leaders and professionals on avoidable management.This would require short and shortcomings in quality and on opportunities long term measures ranging from studying to do better for patients and communities. and adapting innovative management prac- tices in leading public and private hospitals Third,recognizing the key role of patient and establishing an executive management trust for the success of the PCIC model,the program to developing career paths for hos- report recommends that patients are empow- pital managers and working with academic ered with knowledge and understanding of institutions to strengthen and expand degree the health system and be actively engaged in programs in hospital management. the process of seeking care.Optimal use of scarce resources requires that decisions about Fifth,service delivery reform will entail investment and disinvestment in services are realigning incentives and strengthening pur- shaped by patient preferences,which requires chasing.Together with building the skills a two-way communication between multi- of the health labor force (see below),PCIC disciplinary clinical teams and their patients. service delivery requires a supporting set of Without this exchange,decisions are made underlying system-wide incentives that moti- with avoidable ignorance at the front lines vate and influence the behavior and actions of care delivery,services fall short of meeting of health providers in ways that strengthen needs while exceeding wants,and efficiency and sustain the fundamental features of the declines over time. patient-centric model.In addition,financial incentives are a key mechanism of lowering Fourth,the reformed service delivery model costs,improving quality of care and directing requires new roles for hospitals.Public hos- the production and delivery of health services pital reform is part and parcel of reshaping to priority areas determined by the princi- the service delivery system based on PCIC. pals taking such decisions.Designing effec- Internationally,the role of hospitals is chang- tive incentive programs that can align the ing.They are no longer standalone facili- varying objectives of the different stakehold- ties at the center of the delivery system,the ers in health is a complex undertaking,one point of entry to care,or "one-stop shops" that requires regular tweaking and constant
EXECUTIVE SUMMARY xix national agencies dealing with the area of quality have been created in number of countries, including Australia, England, France and the United States. Whatever the option, this entity would serve as the ultimate source of scientific information on all quality-related topics for both clinicians and the public. It will also become the institutional leader in promoting quality of care and ensuring that evidence-based care is consistently delivered at the highest standard. This entity could also serve as a platform for tapping international experience in care improvement. Many OECD countries have established such institutions. Commitment to improving quality of care can be further enhanced by conducting an in-depth national study of the state of quality of care and quality improvement initiatives at all levels of the system. In a number of countries, efforts to improve health system performance are catalyzed by comprehensive, data-based reports on quality and performance. These reports helped focus the attention of leaders and professionals on avoidable shortcomings in quality and on opportunities to do better for patients and communities. Third, recognizing the key role of patient trust for the success of the PCIC model, the report recommends that patients are empowered with knowledge and understanding of the health system and be actively engaged in the process of seeking care. Optimal use of scarce resources requires that decisions about investment and disinvestment in services are shaped by patient preferences, which requires a two-way communication between multidisciplinary clinical teams and their patients. Without this exchange, decisions are made with avoidable ignorance at the front lines of care delivery, services fall short of meeting needs while exceeding wants, and efficiency declines over time. Fourth, the reformed service delivery model requires new roles for hospitals. Public hospital reform is part and parcel of reshaping the service delivery system based on PCIC. Internationally, the role of hospitals is changing. They are no longer standalone facilities at the center of the delivery system, the point of entry to care, or “one-stop shops” for all services. Rather, they are increasingly becoming part of a network of facilities that includes other providers such as primary care, diagnostic units and social services. They are steadily shifting low complexity care to lower levels, and sharing personnel and providing technical assistance and training to them. Moving public hospitals to their new roles in China will require strengthening accountabilities and improving management. Reform will entail enacting a legal framework that specifies organizational forms (such as boards or councils) that serve as the accountable interface between government and hospital management, setting the roles, composition and functions of these boards or councils, granting decision-making autonomy to the same, and putting in place robust accountability mechanisms and incentives that align hospital performance and behaviors with government priorities and the reformed delivery model. China would also benefit from professionalizing hospital management. This would require short and long term measures ranging from studying and adapting innovative management practices in leading public and private hospitals and establishing an executive management program to developing career paths for hospital managers and working with academic institutions to strengthen and expand degree programs in hospital management. Fifth, service delivery reform will entail realigning incentives and strengthening purchasing. Together with building the skills of the health labor force (see below), PCIC service delivery requires a supporting set of underlying system-wide incentives that motivate and influence the behavior and actions of health providers in ways that strengthen and sustain the fundamental features of the patient-centric model. In addition, financial incentives are a key mechanism of lowering costs, improving quality of care and directing the production and delivery of health services to priority areas determined by the principals taking such decisions. Designing effective incentive programs that can align the varying objectives of the different stakeholders in health is a complex undertaking, one that requires regular tweaking and constant
XX DEEPENING HEALTH REFORM IN CHINA adjustment as the different players adapt their promote alternative but well-trained cadres behaviors to changing rules,but fortunately, of health workers(such as clinical assistants, there have been many local experiments in assistant doctors,clinical officers and com- different parts of China in recent years that munity health workers)with eHealth links offer replicable lessons.The main actions nec- to other professionals to strengthen primary essary to realize this vision include:(i)switch care delivery. from fee-for-service as a dominant method of paying providers to capitation,case-mix Seventh,private sector engagement should (i.e.,DRGs),and global budgets;(ii)correct be aligned with the new shape of the deliv- and realign incentives within a single,uni- ery system.China may consider developing form and network-wide design in support of a shared vision of the role of the private sec- population health,quality and cost contain- tor and build the regulatory environment ment;(iii)correct and realign incentives to that allows qualified private actors to deliver reverse the current irrational distribution of cost effective services while competing on a service by level of facilities;and (iv)consoli- level playing field with the public sector.It date and strengthen the capacity of insurance is important that China decides and states funds so as to equip them to become strategic its preferences for select forms and subsec- purchasers. tors in the health sector where it would like private enterprise to focus.This clarity will Sixth,human resources will need to reflect help private investors and health care provid- the new shape of service delivery.PCIC ser- ers as well as subnational governments.The vice delivery requires a competent workforce latter can then develop appropriate supervi- teams and individual practitioners that share sory and regulatory mechanisms to guide the its values,which raises questions of the desir- private sector in ways that best complement able composition of the health workforce in the existing public system of health produc- China.At the center of any PCIC model is tion and delivery.Specific strategies to secure the need to raise the status of primary care this vision include:(i)identify areas where the workers.This will require building consensus private sector can contribute most effectively; and shared understanding among govern- (ii)move away from quantity targets for pri- ment,health providers and general public vate sector market share and instead identify of the centrally important role of primary priority sub-sectors for private sector growth care,together with hospitals,in providing that are most aligned with the public interest; the full continuum of care to the citizens. (iii)endorse the shared vision and articula- Many countries have adjusted their health tion publicly and communicate widely;and workforce in an effort to strengthen primary (iv)formalize the engagement process by health care,and offer useful lessons that can drafting guidelines for provincial and local be applied in the Chinese context.Specific governments to implement according to local implementation strategies include:(i)reform conditions.Government will need to strictly the headcount quota system and establish an monitor the effects of private sector entry independent system of professional licensing and expansion on the health care system and and career development prospects for PHC respond thoughtfully but with agility to what workforce,particularly for general prac- is learned. tice (GP);(ii)introduce primary health care (PHC)-specific career development path to Finally,the report recommends moderniza- develop and incentivize the PHC workforce, tion in ways that capital investment deci- including separate career pathways for GPs, sions are made in the health sector in China, nurses,mid-level workers and community and suggests moving away from the tradi- health workers;(iii)establish general practice tional input-based planning towards capi- as a specialty(such as Family Medicine),with tal investments based upon region-specific equivalent status to other medical specialties; epidemiological and demographic profiles. (iv)enhance compensation system for PHC Shifting from a strategy that is driven by workforce relative to other specialties;and (v) macro standards to one that is determined
xx DEEPENING HEALTH REFORM IN CHINA adjustment as the different players adapt their behaviors to changing rules, but fortunately, there have been many local experiments in different parts of China in recent years that offer replicable lessons. The main actions necessary to realize this vision include: (i) switch from fee-for-service as a dominant method of paying providers to capitation, case-mix (i.e., DRGs), and global budgets; (ii) correct and realign incentives within a single, uniform and network-wide design in support of population health, quality and cost containment; (iii) correct and realign incentives to reverse the current irrational distribution of service by level of facilities; and (iv) consolidate and strengthen the capacity of insurance funds so as to equip them to become strategic purchasers. Sixth, human resources will need to reflect the new shape of service delivery. PCIC service delivery requires a competent workforce teams and individual practitioners that share its values, which raises questions of the desirable composition of the health workforce in China. At the center of any PCIC model is the need to raise the status of primary care workers. This will require building consensus and shared understanding among government, health providers and general public of the centrally important role of primary care, together with hospitals, in providing the full continuum of care to the citizens. Many countries have adjusted their health workforce in an effort to strengthen primary health care, and offer useful lessons that can be applied in the Chinese context. Specific implementation strategies include: (i) reform the headcount quota system and establish an independent system of professional licensing and career development prospects for PHC workforce, particularly for general practice (GP); (ii) introduce primary health care (PHC)-specific career development path to develop and incentivize the PHC workforce, including separate career pathways for GPs, nurses, mid-level workers and community health workers; (iii) establish general practice as a specialty (such as Family Medicine), with equivalent status to other medical specialties; (iv) enhance compensation system for PHC workforce relative to other specialties; and (v) promote alternative but well-trained cadres of health workers (such as clinical assistants, assistant doctors, clinical officers and community health workers) with eHealth links to other professionals to strengthen primary care delivery. Seventh, private sector engagement should be aligned with the new shape of the delivery system. China may consider developing a shared vision of the role of the private sector and build the regulatory environment that allows qualified private actors to deliver cost effective services while competing on a level playing field with the public sector. It is important that China decides and states its preferences for select forms and subsectors in the health sector where it would like private enterprise to focus. This clarity will help private investors and health care providers as well as subnational governments. The latter can then develop appropriate supervisory and regulatory mechanisms to guide the private sector in ways that best complement the existing public system of health production and delivery. Specific strategies to secure this vision include: (i) identify areas where the private sector can contribute most effectively; (ii) move away from quantity targets for private sector market share and instead identify priority sub-sectors for private sector growth that are most aligned with the public interest; (iii) endorse the shared vision and articulation publicly and communicate widely; and (iv) formalize the engagement process by drafting guidelines for provincial and local governments to implement according to local conditions. Government will need to strictly monitor the effects of private sector entry and expansion on the health care system and respond thoughtfully but with agility to what is learned. Finally, the report recommends modernization in ways that capital investment decisions are made in the health sector in China, and suggests moving away from the traditional input-based planning towards capital investments based upon region-specific epidemiological and demographic profiles. Shifting from a strategy that is driven by macro standards to one that is determined
EXECUTIVE SUMMARY by service planning based on real popula- national policy implementation and tion needs will help China better align its monitoring guidelines.Giving more huge capital investments,projected to reach policy weight and providing greater US$50 billion annually by 2020,with the attention to implementation practices demands of an affordable and equitable by senior policy makers and leaders is health care system and achieve value-for- critical to the process of service deliv- money for its massive investments in the ery reform.The central government may health sector.Moving from capital invest- consider having a more "hands-on"role ment planning to a people-centered service in guiding and monitoring the implemen- planning model will require prioritization tation phase of the reforms by the State of public investments according to burden of Council Health Reform Leading Group disease,where people live,and the kind of and in crafting a series of policy imple- care people need on a daily basis.Within this mentation and monitoring guidelines to service planning approach,capital investment orient reform planning and execution by planning,which is necessary to optimally use provincial and local governments.These funding opportunities(such as insurance and guidelines can provide verifiable tasks or public reimbursements),can guide the devel- intermediate outcomes related to reform opment of facilities of the future,change the implementation which would foster status quo of today,and ensure that excess greater reform implementation integrity capacity is not created to further exacerbate at local levels.However,the guidelines inefficiency and capital misallocation. are not an implementation plan or one- size-fits all blueprint.They would need to be operational in nature,specifying Spreading Effective and categorically“what to do.”In turn,.pro- Sustainable Implementation vincial and local governments should have full authority to decide on "how Numerous health reforms experiments are to do it"---developing,executing and under way in China to operationalize the sequencing implementation plans based reform policies,but for the reforms to be on local conditions.These guidelines are successful and brought to scale,they need to best accompanied by a strong monitor- become comprehensive and be implemented ing system with corresponding indica- in a coordinated and deliberate manner. tors capable of independently assessing Bridging the gap between policies and prac- and verifying implementation progress tice requires capacity,resources,accountabil- and results(see below).Finally,the State ity and a commitment to collaboration,eval- Council Health Reform Leading Group uation and learning.The report recommends can craft strong accountability mecha- putting in place a simplified but actionable nisms to enforce reform implementation implementation framework consisting of four at provincial and local levels.For exam- systems adapted broadly to the Chinese con- ple,the aforementioned indicators can be text:(1)macro implementation and (external) placed in“task agreements”with pro- influence system;(ii)coordination and sup- vincial and local government.For some port system;(ii)delivery and learning system; provinces and local governments where and (iv)monitoring and evaluation system. institutional capacity is lacking,the cen- The following specific recommendations tral government may want to consider would contribute to creating an enabling financing and arranging for technical organizational,accountability and collabora- support on implementation. tive environment for sustained and scalable Coordination and support system: implementation. Establishing coordination and organi- zational mechanisms that make provin- Macro implementation and (external) cial and local governments accountable influence system:Establishing strong for results and support front line reform central government oversight linked to implementation.The coordination and
EXECUTIVE SUMMARY xxi by service planning based on real population needs will help China better align its huge capital investments, projected to reach US$ 50 billion annually by 2020, with the demands of an affordable and equitable health care system and achieve value-formoney for its massive investments in the health sector. Moving from capital investment planning to a people-centered service planning model will require prioritization of public investments according to burden of disease, where people live, and the kind of care people need on a daily basis. Within this service planning approach, capital investment planning, which is necessary to optimally use funding opportunities (such as insurance and public reimbursements), can guide the development of facilities of the future, change the status quo of today, and ensure that excess capacity is not created to further exacerbate inefficiency and capital misallocation. Spreading Effective and Sustainable Implementation Numerous health reforms experiments are under way in China to operationalize the reform policies, but for the reforms to be successful and brought to scale, they need to become comprehensive and be implemented in a coordinated and deliberate manner. Bridging the gap between policies and practice requires capacity, resources, accountability and a commitment to collaboration, evaluation and learning. The report recommends putting in place a simplified but actionable implementation framework consisting of four systems adapted broadly to the Chinese context: (i) macro implementation and (external) influence system; (ii) coordination and support system; (ii) delivery and learning system; and (iv) monitoring and evaluation system. The following specific recommendations would contribute to creating an enabling organizational, accountability and collaborative environment for sustained and scalable implementation. • Macro implementation and (external) influence system: Establishing strong central government oversight linked to national policy implementation and monitoring guidelines. Giving more policy weight and providing greater attention to implementation practices by senior policy makers and leaders is critical to the process of service delivery reform. The central government may consider having a more “hands-on” role in guiding and monitoring the implementation phase of the reforms by the State Council Health Reform Leading Group and in crafting a series of policy implementation and monitoring guidelines to orient reform planning and execution by provincial and local governments. These guidelines can provide verifiable tasks or intermediate outcomes related to reform implementation which would foster greater reform implementation integrity at local levels. However, the guidelines are not an implementation plan or onesize-fits all blueprint. They would need to be operational in nature, specifying categorically “what to do.” In turn, provincial and local governments should have full authority to decide on “how to do it” --- developing, executing and sequencing implementation plans based on local conditions. These guidelines are best accompanied by a strong monitoring system with corresponding indicators capable of independently assessing and verifying implementation progress and results (see below). Finally, the State Council Health Reform Leading Group can craft strong accountability mechanisms to enforce reform implementation at provincial and local levels. For example, the aforementioned indicators can be placed in “task agreements” with provincial and local government. For some provinces and local governments where institutional capacity is lacking, the central government may want to consider financing and arranging for technical support on implementation. • Coordination and support system: Establishing coordination and organizational mechanisms that make provincial and local governments accountable for results and support front line reform implementation. The coordination and
xxii DEEPENING HEALTH REFORM IN CHINA support system requires an organiza- institutional fragmentation on reform tional structure proximate to front line implementation.It does not institutional- implementation to carry out a number of ize inter-agency coordination.A longer critical functions,including coordinat- term solution would involve institutional ing and ensuring buy in of key institu- consolidation which would be part of a tional stakeholders,arranging for train- much broader reform to streamline the ing and technical assistance,developing government's administration systems and adapting implementation plans and and organizational structures.China timelines,communicating reform activi- may want to examine organizational ties and expectations to communities, structures,distribution of responsibili- health care organizations and health ties and coordination of functions across workers,and making front line providers agencies involved in health system gover- accountable for implementation progress nance in OECD,especially those coun- and results.Strengthening accountability tries with social insurance financing and arrangements is of crucial importance, mixed delivery systems (i.e.,public and particularly at the provincial and local private provision). levels.Any accountability arrangement Delivery and learning system:Creating should be sufficiently powerful to align "Transformation Learning Collabora- institutional standpoints and to lever- tives"(TLCs)at the network and facil- age government interests when dealing ity levels as the fundamental building with providers and vested interests.One block to implement,sustain and scale option is to promote and strengthen the up reforms on the front line.The main empowered“leading groups”or steer- location of implementation is the front ing committees at the provincial level lines of service delivery:health care led by government leaders (i.e.,gover- organizations(hospitals,THCs,CHCs, nors,mayors or party chiefs),follow- VCs),networked groups of health care ing the practice in some provinces or organizations,and communities.Health municipalities.Leading groups can also care organizations must adopt con- be formed at local governmental levels tinuous learning and problem-solving (county,municipality,and prefecture) approaches to accelerate the success- depending on the context.Such groups ful implementation of reforms.To do already exist in China-Sanming is an this will require local customization example-and they have played impor- of policy implementation guidelines to tant role in coordinating health service meet specific needs at the front-lines.To delivery and health insurance reforms support this learning process,it may be at local level.The leading groups will beneficial for public and private provid- require strong leadership and politi- ers to come together to form associations cal support and be fully empowered to committed to implementing the PCIC implement reform within their jurisdic- approach and corresponding reforms in tions.A subset of these implementation the financial and institutional environ- performance measures can be considered ment.China can consider forming TLCs for incorporation into the career pro- partnerships of groups of facilities motion system for provincial and local within a county,district,or municipal- leaders.An advantage of the proposed ity (CDM)-to implement,manage,and leading group arrangement is that it is sustain reforms on the front lines.The a well-known inter-agency coordination driving vision behind the TLC concept mechanism,and has been applied suc- is to assist and guide local care sites (e.g., cessfully within the current institutional village clinics,THCs,CHCs,county framework.Nevertheless,the "lead- and district hospitals)to implement ing group"option can be considered as and scale-up the reformed service deliv- an interim organizational arrangement ery model and close the gap between in part to mitigate the challenges of “knowing”and“doing.”Ostensibly
xxii DEEPENING HEALTH REFORM IN CHINA support system requires an organizational structure proximate to front line implementation to carry out a number of critical functions, including coordinating and ensuring buy in of key institutional stakeholders, arranging for training and technical assistance, developing and adapting implementation plans and timelines, communicating reform activities and expectations to communities, health care organizations and health workers, and making front line providers accountable for implementation progress and results. Strengthening accountability arrangements is of crucial importance, particularly at the provincial and local levels. Any accountability arrangement should be sufficiently powerful to align institutional standpoints and to leverage government interests when dealing with providers and vested interests. One option is to promote and strengthen the empowered “leading groups” or steering committees at the provincial level led by government leaders (i.e., governors, mayors or party chiefs), following the practice in some provinces or municipalities. Leading groups can also be formed at local governmental levels (county, municipality, and prefecture) depending on the context. Such groups already exist in China – Sanming is an example – and they have played important role in coordinating health service delivery and health insurance reforms at local level. The leading groups will require strong leadership and political support and be fully empowered to implement reform within their jurisdictions. A subset of these implementation performance measures can be considered for incorporation into the career promotion system for provincial and local leaders. An advantage of the proposed leading group arrangement is that it is a well-known inter-agency coordination mechanism, and has been applied successfully within the current institutional framework. Nevertheless, the “leading group” option can be considered as an interim organizational arrangement in part to mitigate the challenges of institutional fragmentation on reform implementation. It does not institutionalize inter-agency coordination. A longer term solution would involve institutional consolidation which would be part of a much broader reform to streamline the government’s administration systems and organizational structures. China may want to examine organizational structures, distribution of responsibilities and coordination of functions across agencies involved in health system governance in OECD, especially those countries with social insurance financing and mixed delivery systems (i.e., public and private provision). • Delivery and learning system: Creating “Transformation Learning Collaboratives” (TLCs) at the network and facility levels as the fundamental building block to implement, sustain and scale up reforms on the front line. The main location of implementation is the front lines of service delivery: health care organizations (hospitals, THCs, CHCs, VCs), networked groups of health care organizations, and communities. Health care organizations must adopt continuous learning and problem-solving approaches to accelerate the successful implementation of reforms. To do this will require local customization of policy implementation guidelines to meet specific needs at the front-lines. To support this learning process, it may be beneficial for public and private providers to come together to form associations committed to implementing the PCIC approach and corresponding reforms in the financial and institutional environment. China can consider forming TLCs – partnerships of groups of facilities within a county, district, or municipality (CDM) –to implement, manage, and sustain reforms on the front lines. The driving vision behind the TLC concept is to assist and guide local care sites (e.g., village clinics, THCs, CHCs, county and district hospitals) to implement and scale-up the reformed service delivery model and close the gap between “knowing” and “doing.” Ostensibly