Introduction
It is rare to find individual accounts in social protection for health, mainly because their saving function counteracts the social-solidarity value of social insurance. However, China innovated a national health social security plan following the controversial principle of ‘social pooling plus individual accounts’ in the 1990s. After a decade-long operation, inefficient resource utilisation and substantial fund imbalance proved the individual accounts detrimental to social health security. The policy hybrid divested itself of the individual accounts, and the individual accounts have faced the fate of exnovation, namely a removal or termination of outdated or malfunctioned innovations (Verger, Duymedijian and Roberts, Reference Verger, Duymedjian and Roberts2024; Hartly & Knell, Reference Hartley and Knell2022; Kimberly, Reference Kimberly, Nystrom and Starbuck1981). This paper attempts to explain the birth of China’s health policy hybrid and explore the life courseFootnote 1 (namely the innovation and exnovation) of individual health accounts.
Policy hybrids have received scholarly attention since the 1980s. Examining the claim of ‘East Asian social welfare regimes’ (see Jones, Reference Jones and Jones1993; Midgley, Reference Midgley1986), Goodman and Peng (Reference Goodman, Peng and Esping-Andersen1996) concluded that East Asian countries selectively adopted Western social policy models through peripatetic learning to (re)assemble their welfare systems and (re)construct nation-building. ‘These regimes, like Japan, have incorporated many aspects of Western social welfare ideas, but, in practice, deviated fundamentally from West experience’ (Goodman & Peng, Reference Goodman, Peng and Esping-Andersen1996, p.194). Esping-Andersen (Reference Esping-Andersen1997) joined the discussion and argued that the Japanese hybrid welfare system was not a unique model but a fusion of European and American welfare state styles. Although the conceptual repository of his Three Worlds of Welfare Capitalism (1990) is insufficient to interpret East Asian cases, Esping-Andersen (Reference Esping-Andersen1997) considered their social policy proliferation as ‘extending democratic and social rights’ (p.180), which lacked a unique institutional constitution. Subsequently, 1 year later, Goodman and his colleagues published their findings on the existence of an ‘East Asian welfare model’. On the basis of five case studies, White and Goodman (Reference White, Goodman and Goodman1998) not only confirmed the distinctiveness of East Asian welfare experiences but also underlined the importance of ideological discourses for East Asian policy learning.
Currently, two research avenues exist for making sense of policy hybrids. The first research strand aligns with Esping-Andersen. This literature body assumes that the hegemony of Western culture leads to the convergence of global social policy, and values such as democracy, rationality, equality and individualism penetrate nation states and their institutions globally (Meyer, Reference Meyer1980; Meyer, Reference Meyer2010; Deacon & Stubbs, Reference Deacon and Stubbs2013). The policy deviations result from ‘war of positions’ or disagreement among International Organizations (Kaasch, Reference Kaasch2013; Hu, Reference Hu2016). Whereas the second research strand aligns with Goodman and his colleagues. This literature body originates from policy diffusion research (Rogers, Reference Rogers1962; Walker, Reference Walker1969; Gilardi, Reference Gilardi, Carlsnaes, Risse and Simmons2012), which proposes competition, coercion, emulation and learning as major diffusion mechanisms (Kuhlmann, Reference Kuhlmann and Porto de Oliveira2021) to explain the policy innovations or hybrids with due consideration to the interdependence between endogenous and exogenous factors, such as international influence (Duckett, Reference Duckett2019), rationality (Rose, Reference Rose1991), cognitive heuristics (Weyland, Reference Weyland2005), travelling knowledge (Bandelow, Reference Bandelow and Maier2003; Leisering & Liu, Reference Leisering and Tao2010) and synthesis of ideas (Leisering, Liu & ten Brink, Reference Leisering, Liu and ten Brink2017).
The blinding point of the first research strand lies in its West-centralism, thereby oversimplifying the dynamics of Western influence (White & Goodman, Reference White, Goodman and Goodman1998, pp.5–7), which could be addressed by policy diffusion studies that enrich the contents of policy decoupling. However, diffusion is defined as ‘government policy decisions in a given country are systematically conditioned by prior policy choices made in other countries’ (Simmons et al., Reference Simmons, Dobbin and Garrett2006, p.787), and the political dimension of diffusion is undermined (Gilardi & Wasserfallen, Reference Gilardi and Wasserfallen2019). The framework of policy diffusion often falls short of explanatory clarity (Heinze, Reference Heinze2011), and existing research provides only a static horizontal picture of policy adoptions among countries (Gilardi et al., Reference Gilardi, Shipan and Wüest2021), which casts limited light on the dynamics of policy innovations or hybrids within a country.
Recently, the concept of ‘bricoleur’ has been employed to discuss ideational and institutional changes (Carstensen, Reference Carstensen and Spanakos2015). As an effective action to maintain institutional resilience amid uncertainty (Cleaver, Reference Cleaver2012, p.34; Weick, Reference Weick1993) or ‘bolster incremental innovation’ (Ciborra, Reference Ciborra2002, p.51), ‘bricoleur’ increases institutional sustainability by ensuring functionality, yet it also disrupts the original institutional dynamics and undermines institutional stability. ‘Bricoleur’ is characterised by a cyclic process of building-up and falling-apart where the basic components are derived from fragments or events from the past (Lévi-Strauss, Reference Lévi-Strauss1966, pp.20–21), and the assembled elements hardly survive for good but own a life course. Furthermore, bricolage is considered beneficial for analysing the politics of global governance and revealing how global policy-making unfolds (Pouliot & Thérien, Reference Pouliot and Thérien2023). Therefore, ‘bricoleur’ not only has a good connection to global policy and diffusion studies but also provides an analytical lens to scrutinise policy’s life course.
This paper examines the life course of China’s innovative health policy hybrid of ‘social pooling plus individual accounts’ from the perspective of ‘bricoleur’. Firstly, this study contributes to revisiting the debate on the uniqueness of East Asian welfare regimes (Esping-Andersen, Reference Esping-Andersen1997; Goodman & Peng, Reference Goodman, Peng and Esping-Andersen1996). Secondly, this study reflects on global social policy studies and explores policy diffusion mechanisms. Most policy diffusion research has focused on horizontal S-shaped diffusion curves (Gray, Reference Gray1973) or diffusion life course across various states (Mallinson, Reference Mallinson2021), which followed an adoption-centred lens and neglected the exnovation process as a part of the life course of diffused policy innovations. Last, regarding novel policy practices, such as hybrids, people usually discuss innovation and ignore exnovation. Exnovation is integral to innovation (Verger, Duymedijian & Roberts, Reference Verger, Duymedjian and Roberts2024; Hartly & Knell, Reference Hartley and Knell2022; Kimberly, Reference Kimberly, Nystrom and Starbuck1981). Giving equal attention to the bright and dark sides of innovation (Hartly & Knell, Reference Hartley and Knell2022, pp.40–41) could contribute to the effective handling of policy innovations and welfare changes.
Conceptual framework and research methods
Lévi-Strauss (Reference Lévi-Strauss1966, p.17) proposed an analogy pair of ‘bricoleur’ and ‘ingénieur’ to shed light on two thinking or knowledge-based action regimes (Duymedijian & Rüling, Reference Duymedjian and Rüling2010) in our societiesFootnote 2 . Bricoleur is characterised by handymen or handywomen’s ‘doing things with whatever is at hand’ (Lévi-Strauss, Reference Lévi-Strauss1966, p.17), while ingénieur suggests scientists’ tradition of inquiry derived from the Enlightenment movement. Bricoleur relies on mythical thought to address ‘himself to a collection of oddments left over from endeavors, that is, only a sub-set of the culture’ (Lévi-Strauss, Reference Lévi-Strauss1966, p.19).
The characteristic feature of mythical thought is that it expresses itself by means of a heterogeneous repertoire which, even if extensive, is nevertheless limited. It has to use this repertoire; however, whatever the task at hand, because it has nothing else at its disposal. Mythical thought is therefore a kind of intellectual ‘bricolage’… (Lévi-Strauss, Reference Lévi-Strauss1966, p.17)
As a mythical-thought-based action regime (Duymedijian & Rüling, Reference Duymedjian and Rüling2010), bricoleur uses signs converse with its ‘stock’ – heterogeneous resource elements from accessible culture. The process of bricolage comprises assembling, substituting and synthesizing ‘elements based on simple rules to yield an original composition’ (Duymedijian & Rüling, Reference Duymedjian and Rüling2010, p.134) to maintain the functional structure. Although bricolage is ‘an assembly of different objects that remain visible as such’ (Duymedijian & Rüling, Reference Duymedjian and Rüling2010, p.138), the patchwork deviates from proportion standards of the existing project (Reinhardt, Reference Reinhardt2008, p.113). The outcome of bricolage is hard to anticipate as its initial aim is only a sketch consisting of signs or imaginations (Lévi-Strauss, Reference Lévi-Strauss1966, p.21). In a nutshell, mythical thought leads to a ‘compromise between the structure of the instrumental set and that of the project. Once it materializes the project will therefore inevitable be at a remove from the initial aim’ (Lévi-Strauss, Reference Lévi-Strauss1966, p.21).
This case study investigates the life course of China’s health policy hybrid from 1979 to the 2010s with a focus on individual accounts. The analysis is based on examining primary and secondary data, including expert interviewsFootnote 3 , newspaper reports, archival documentation, memoirs, journal articles and books. The expert interviews provide a narrative outline for the Chinese health policy-making process through personal experiences, while the literature review and the archive research verify and enrich the oral storytelling with detailed historical facts. From August 2018 to December 2019, I conducted fieldwork in China and collected 46 expert interviews with a semi-structured questionnaire. Snowball sampling was used to select interviewees. Informed consent was obtained verbally before the conduct of interviews, and the sources were carefully anonymised. The interviewees were prominent scholars, renowned think tanks, multi-level officials, retired policy advisers and other participants in China’s health policy-making. During my fieldwork, I not only visited social health insurance departments at the rural and urban levels but also took part in national and international discussions on China’s social health policy-making, such as a governmental closed-door international conference and a governmental bidding and evaluation meeting. I also travelled to historically crucial policy pilot places, such as the Jiangsu Province, where one of the two-river health reform experiments was undertaken. I consulted archives and exclusive reference rooms of different institutes for historic or internal material, such as the Chinese Academy of Labour and Social Security, the China Institute for Reform and Development, the National Library of China and the Renmin University of China. The data came from various sites in different languages to balance narrative standpoints and minimise bias and prejudice.
The analysis begins with a brief historical review of China’s social protection development. Next, I illustrate the life course of individual health accounts from 1979 to the 2010s to depict the bricolage process at the ideational and practical levels. Finally, research findings and further implications are presented.
Making daily-life risk protection culturally acceptable
Modern insurance was first introduced to China by foreign commercial companies in the 1800s. Following marine and fire insurances, casualty insurance entered China in the 1870s but suffered a hard sell owing to the cultural taboo on openly discussing death or risks. In the early 20th century, the insurance companies altered Chinese aversion to casualty insurance and boosted the sales by appealing to the Chinese culture disposition, such as saving habits and family responsibility. ‘Insurance companies advertised the benefits of insurance to provide for an estate and sold predominately short-term policies which worked not only as insurance but also as saving’ (Swiss Re Corporate History, 2017). The success marked a new era for China’s insurance industry, and risk management for daily life became culturally acceptable.
In the 1920s, rudimentary modern social insurance diffused to China. Motivated by the Great October Socialist Revolution and Lenin’s national labour insurance plan, the Communist Party of China strove to improve working conditions, including healthcare subsidies and sick pay, through labour insurance regulations. In 1949, the provisional constitution of the People’s Republic of China announced that compulsory labour insurance should be established to secure workers’ fundamental rights to their livelihood. The national labour insurance scheme was adapted from the Soviet Union’s labour regulationsFootnote 4 . As a trendy slogan went: ‘Socialism is good, life and death are insured by labour insurance’ (Zhou & Zhang, Reference Zhou and Zhang2015, p.9). The Soviet-style national labour insuranceFootnote 5 took root in China, and the government was the major provider for people’s social protection.
Unlike the German social insurance model, China’s labour health insurance was operated in tandem with a socialised health system, where the pricing and staffing were planned by the central government (Field, Reference Field1973). About financing mechanisms, the labour insurance had a risk-pooling function comparable to the German one. Of the labour insurance premiums, 70% stayed in the enterprises as the workers’ risk pooling funds (mostly at the working-unit level), and the remaining 30% flowed into the national trade union for the staffs nationwide (Zhao, Jiang & Liu, Reference Zhao, Jiang and Liu1993, p.388). Nevertheless, because of the crisis of the trade unions between 1966 and 1976, the labour insurance lost its national social-pooling ability, downgraded its social-pooling level to enterprises and thus became a working-unit-based insurance.
Social security reform under the economic transition pressure
In 1979, China decided to transform its planned economy into a socialist market economy, and the deficits of the working-unit-based welfare arrangements were further revealed, such as inadequate financial sustainability, the hindrance to labour mobility and the restrain on market competition.
The Soviet-style social security system was forced to change. In 1982, the central government addressed the double standard problem of social responsibility distribution among state-owned and other enterprises, where the uneven pension burden was underlined as one of the most urgent reform needs. Influenced by Chinese–American professors and Jewish-American scholarsFootnote 6 , China developed a belief that social security should match the market economy, social conditions and people’s needs (Interview no. 9; Zhu, Reference Zhu2011). In 1985, the 7th Five-Year Plan of the People’s Republic of China set the tone for China’s social security plan, and its Article 62 stated:
[E]stablishing new social security system is a necessary condition for implementation and success of the economic reform as well as a top-level plan for social stability and long-term prosperity…The construction of national social security should be based on China’s current national circumstances and capabilities…Social security funds should be raised jointly by the state, enterprises and individuals…Footnote 7
In response, the Ministry of Labour held China’s first academic conference on social insurance and welfare in 1983 and organised national training workshops in collaboration with the International Labour Organisation (ILO) in 1986. The German social insurance model was considered a promising solution to cope with the welfare reform (Zhou & Zhang, Reference Zhou and Zhang2015).
As social security reform was defined as a supplementary program to facilitate marketisation, the State Council Office for Restructuring the Economic System joined the welfare reform debate. The office comprised economists and high-ranking political figures, eager to learn from foreign development experiences. With the increasing collaboration with the World Bank (WB) and the warming diplomatic relations with Singapore, the office identified the Chilean pension privatisation reform and the Singaporean individual accumulation-fund model as exemplary for China. Singapore’s individual account approach could represent East Asian culture and foster national economic development, and Chile’s transition to an accumulation-fund-dominated old-age protection system offered valuable implementation experience for China’s social security reform (Deng, Reference Deng2015, pp.98–99).
The spill-over of the pension model into the health domain
In 1991, under the supervision of the Mayor of Shanghai Zhu RongjiFootnote 8 , Shanghai pioneered the pension reform approach of integrating social insurance with individual accounts, which drew lessons from Singapore’s central provident fund and Chile’s privatisation practices (Liu, Reference Liu1995, pp.71–88). The Shanghai model was later commended nationwide for its achievement in exploring a Chinese-tailored reform model (Liu, Reference Liu1995, p.72).
In 1993, the 3rd Plenary Session of the 14th Central Committee announced that the top-level reform plan for urban pension and health protection should follow the ‘social pooling plus individual accounts’ model in the Decision of the Central Committee of the Communist Party of China on Some Issues concerning the Establishment of the Socialist Market Economy (Deng, Reference Deng2015, pp.98–99). In 1994, the central government tasked the State Council Office for Restructuring the Economic System with establishing a Social Security Reform Study Group to draw up a detailed top-level social security reform plan to accelerate the transformation towards a modern enterprise system (Liu, Reference Liu1995, p.1). After an in-depth investigation, the prevailing view among the group members was that Shanghai’s pension model of the ‘social pooling plus individual accounts’ constituted a significant breakthrough in China’s social security reform and thus was of value to promote widely (Liu, Reference Liu1995, p.273). Meanwhile, the Ministry of Labour also started experimenting with adding individual accounts to the German social insurance model (Zhu & Zhang, Reference Zhu and Zhang1995, p.172; Hu, Reference Hu2012). In 1994, Vice Premier Zhu Rongji and President Jiang Zemin agreed on the national reform plan of ‘social pooling plus individual accounts’ after listening to the study group’s reports (Liu, Reference Liu1995, p.29).
In the 1990s, it was a political consensus that China’s social security standard should commensurate with economic development where individuals, enterprises and governments were responsible for funding social insurance to ensure efficiency and fairness. Fairness was associated with enterprise competition on a level playing field, while efficiency underlined individual responsibility for economic productivity. The German social insurance model symbolised fairness as it could distribute social responsibility or burden through large-scale risk-pooling to ensure competition fairness among enterprises. The Singaporean individual account model represented efficiency because it corresponded to the principle of ‘more pay for more work’, which could not only incentivise labour enthusiasm but also increase enrolment rates (Liu, Reference Liu1995, pp.35–155; Wu, Reference Wu2003, p.239).
The government mainly referred to Shanghai’s pension reform experience to crystalise a national reform scheme, namely the ‘social pooling plus individual accounts’ model, and this hybrid model spilled over to the health domain through administrative requirements.
Mélange of ideas: culture grafting mechanism
In the early 1990s, some scholars interpreted Shanghai’s pension reform as grafting individual accounts to social insurance to form a mixed pension reform model (Hu, Reference Hu2019, p.150). The notion of ideational grafting could be traced back to the health domain as early as 1987, when the Ministry of Health’s Expert Committee advocated improving or reforming China’s health protection by grafting suitable international practices (Cao, Reference Cao2014, pp.153–154).
A retired adviser (Interview no. 1) remembered that the mix of social insurance and individual accounts resulted from a problem-oriented policy design process.
As for Singapore, it was the Chinese government that took the initiative to visit and learn…China was inspired by Singapore’s Central Provident Fund, especially about pension…We created our reform plan by adapting Singapore’s experiences to our national conditions. We studied Singapore’s model carefully. After foreign tours, special meetings were held…Initially, finding such a model quite novel, we thought it could be suitable for us because it could cope with our system’s problems. However, as we studied further, we discovered that Singapore’s individual account model differed from what we thought…We could still learn from it and design a new one ourselves…We absorbed it into our reform plan because the adoption benefits outweighed the disadvantages…(Interview no. 1).
In the late 1980s, the adoption of individual health accounts was debatable. The proponents hailed it as a potentially impactful health reform mechanism that could increase individual responsibility for social security, control medical waste, manage health expenditure growth and prepare for personal future medical bills (Zhou & Zhang, Reference Zhou and Zhang2015, p.194). The opponents criticised the individual accounts for diluting the social risk-pooling effect, eroding social solidarity and creating an illusion that these accounts could have a saving function for old age similar to pension ones (Interview no. 1; Liu, Reference Liu1995, p.151).
At last, the advocates gained the upper hand through a grafting argument. From the mechanism perspective, individual accounts could motivate people to use the funds and medical resources efficiently, which echoed the major health reform concerns (Zhao, Jiang & Liu, Reference Zhao, Jiang and Liu1993, p.271). It could avert the tragedy of commons by grafting this mechanism to the German social insurance model. From the culture perspective, China lacked an institutional foundation to operate social health insurance because of historical, cultural and sociopsychological depositions, such as the family-centred social structure with a low social autonomy (Interview no. 2; Wang, Reference Wang2013). It could make the social reform more acceptable and attractive to people by adding the East-Asian-value-oriented individual accounts (Interview no. 3; Interview no. 4). Notwithstanding the acknowledgment of the heterogeneity or logic rupture, the two elements were synthesised.
In 1994, Zhu Rongji, as a supporter of individual accounts, explained that reform should consider China’s microeconomic development in the last thousands of years: ‘We lack the concept of the rule of law, have no idea of insurance, and are not used to many things. If the social security completely transformed into the social pooling model suddenly, people cannot stand such a radical concept change…The individual account model is conducive to fund-raising at employee and enterprise levels. Workers can urge enterprises to enforce it. Without individual accounts, contributions and fees cannot be collected’. (Wang, Reference Wang2013, p.82)
Apart from the Ministry of Health’s Expert Committee’s description of the mechanism-grafting approach (Cao, Reference Cao2014, pp.153–154), an interviewee from a ministry-level state think tank articulated that the ‘social pooling plus individual accounts’ model resulted from ‘cultural grafting’ (Interview no. 5) against the backdrop of globalization and China’s moderation tradition.
Social security is being globalised, as countries exert influence on one another. However, such influence does not directly lead to policy model imitation. It is based on its tradition when a state absorbs or learns cultures and techniques…People have their traditions, and the Chinese pursue the middle way or the golden mean…During the social security reform, Western culture also tried to influence China, and when we could not decide which path to choose, we followed the principle of the golden mean…The model of ‘social pooling plus individual accounts’ resulted from a cultural grafting approach amid international impact…Throughout the globalisation process, our culture has been seeking common ground with, clashing with, learning from and drawing on Western values (Interview no. 5).
To cope with industrialization challenges, the policy-makers adopted the attitude of the golden mean derived from a Confucian Classic of Doctrine of the MeanFootnote 9 , and the policy-making process strove for a balance between modernity and tradition. The element of individual accounts was introduced as a symbol of efficiency to remedy the low social productivity of previous communist egalitarianism and a sign of East Asian values to deal with possible operation difficulties of the German social insurance.
Bricoleur in practice: old wine in new bottles
Besides the ideational grafting, the practical foundation was equally important to the policy bricolage. A sufficient ground that economic and old-age policy ideas could spill over into the health domain was that a matching policy terrain or repertoire existed. Although individual accounts were formally introduced into the health policy domain by the 3rd Plenary Session of the 14th Central Committee in 1993, the design for social health protection funds had already been divided into two parts, namely social and personal funds (Hu, Reference Hu2019, p.162).
The pre-late 1980s health experiments yielded valuable insights for policy-makers to implement the social security reform guideline of 1985, which emphasised joint responsibility of the state, enterprises and individuals. In the 1960s, China’s health security system was plagued by soaring healthcare expenditure and public financing pressure. The central government mobilised ministries and local authorities to experiment with reform measures, and finally, two strategies took shape in the 1980s (Zhao, Jiang & Liu, Reference Zhao, Jiang and Liu1993; Zhu & Zhang, Reference Zhu and Zhang1995).
The first strategy could date back to 1961 when the state-funded hospitals adopted the measure of ‘individual average annual health expenses’ to ration healthcare resources per person to predict or control the annual due public healthcare expenditure. This measure evolved into the rigid individual lump-sum approach for labour health insurance reimbursement in the 1970s and then became a part of the out-of-pocket strategy in the 1980s. It was believed that the out-of-pocket strategy could contain the growth of health costs and reduce the financial deficit of the healthcare system by emphasising individual responsibility. The Ministry of Health was in favour of this strategy (Zhao, Jiang & Liu, Reference Zhao, Jiang and Liu1993, pp.287–290).
The second strategy was inspired by Beijing’s Vegetable Company of Dongcheng District, which built an enterprise-based risk-pooling insurance fund for critical sicknesses in 1987. This practice enormously appealed to the Ministry of Labour, which dedicated itself to promoting the social pooling approach for pension reform in 1984. Sponsored by the Ministry of Labour, the vegetable company’s practice evolved into a social-pooling insurance model for critical sicknesses. It was believed that this model could overcome the workers’ reimbursement difficulties, guarantee timely medical treatment, release the financial burden of enterprise and public welfare and smooth the economic reform (Zhao, Jiang & Liu, Reference Zhao, Jiang and Liu1993, pp.288–897; Zhu & Zhang, Reference Zhu and Zhang1995, pp.383–671).
In March 1988, the central government formed the Discussion Group for National Health Reform. This group gathered the Ministry of Health, the State Council Office for Restructuring the Economic System and the Ministry of Labour to collaborate on integrating the abovementioned strategies to formulate an urban health reform plan. Their proposal mainly comprised two parts: a social-pooling fund only for inpatient reimbursement or critical sicknesses plus an individual out-of-pocket payment mechanism. After approving this reform plan, the state circulated the Notice of the State Council Office for Restructuring the Economic System on Key Work for the Reform of the Economic System to enact regional social security reform experiments in 1989. Unfortunately, this reform attempt failed because the cancellation of reimbursement for common ailments or outpatient services undermined the reform incentives. Cutting back on outpatient reimbursement provoked widespread resentment and harmed the interests of policy clientele who were supposed to enforce the policy reform measures (Deng, Reference Deng2015, p.101; Zheng, Reference Zheng2002, p.133; Zhu & Zhang, Reference Zhu and Zhang1995, p. 670; Interview no. 6).
The health reform attempts in the 1980s ended up with nothing conclusive, except for teaching policy-makers a lesson on the stakeholders’ sensitivity to outpatient reimbursement and the necessity of bridging the old and new health benefit schemes. Despite the absence of a successful health reform experiment, the central government promulgated the ‘social pooling plus individual accounts’ model as the top-level urban health reform plan in 1993, started experimenting with this model in two riversFootnote 10 in 1994 and promoted it nationwide in 1998.
During the reform, especially regarding the socialisation of insurance management, the new system had a limited management capacity and was reluctant to regulate outpatient services. To put it differently, the new policy scheme only wanted to protect critical sickness risks because such illnesses had a low risk and were easy to regulate. However, it was not possible to remove the outpatient benefits which had been available for a long time. Against this backdrop, the rigid individual lump-sum approach, which had been used for regulating outpatient expenditure, slowly evolved into the predecessor of individual accounts during the then exploring process (Interview no. 7).
There is nothing new under the sun. In the early 20th century, commercial insurance companies added a saving function to casualty insurance to boost sales. Drawing lessons from the past policy failureFootnote 11 , the government combined individual accounts with social health insurance to sustain outpatient reimbursement and gain wider acceptance.
The national health insurance reform experiments in two rivers were introduced in 1994 following the ‘social pooling plus individual accounts’ model. Such a model combined the Western-European social insurance and the saving-based individual account from Singapore and Chile. The social-pooling insurance took over the function of critical sickness funds or inpatient reimbursement in the old social health protection system, and the individual accounts corresponded to the rigid individual lump-sum approach for outpatient services in the labour health insurance and the state-funded public health system. In other words, the reason behind choosing this model was our consideration of the necessity to bridge the gap between the new social health insurance scheme and the old state-funded health protection system. (Peng, Reference Peng2010, p.191)
Peng Ruicong, former secretary of the Party Committee of Beijing Medical University and a witness to China’s health policy reform since the 1950s, indicated a cross-section of the health policy reform logic, namely putting old wine in new bottles. Although modern social policy models were introduced, the general health benefit structure remained. The labour health insurance and the rigid individual lump sum shared a great affinity with the German social insurance and the Singapore individual accounts, which offered favourable conditions for substituting or replacing. By referring to foreign ideas, the government devised existing policy repertoire to suit the new policy scheme and presented old practices in a modern way.
Demystification of bricolage: the downfall of individual health accounts
After the successful promotion of the social health insurance for urban employees in 1998, the ‘social pooling plus individual accounts’ model was extended to social protection schemes for other populations (Shen & Hou, Reference Shen and Hou2011, p.75), and the individual accounts were considered useful for reducing reform resistance and increasing enrolment rates (Shen, Reference Shen2019, p.77).
The adoption of the individual account model has sparked controversy in public discourse since the 1990s. In 1998, the editors of the journal China Social Security organised a forum titled ‘China’s health reform across the century’, where prominent experts highlighted the practical and theoretical weaknesses of the individual accounts. Practically, the individual accounts undermined fund operations and induced patient–doctor complicity in resource abuse. Theoretically, the individual accounts lacked a clear-cut functioning scope in the health protection system, and the reimbursement division between social-pooling and individual funds varied across regions. The criticism raised the question of whether China should relinquish the innovative policy hybrid. At last, the discussion concluded with a consensus that, currently, the advantages of individual accounts outweighed the disadvantages (Zheng & Yang, Reference Zheng and Yang1998).
Over time, the limitations of the individual accounts became pronounced, and doubts about them resurfaced in public discourse. Since 2005, a growing amount of empirical research has shown that the individual health accounts caused growing problems (e.g. Wang, Reference Wang2005; Fu, Reference Fu2005; Liu et al., Reference Liu, Dong, Meng and Yan2006; Cong, Reference Cong2006; Shen & Hou, Reference Shen and Hou2011; Wang & Li, Reference Wang and Li2015; Hua, Reference Hua2020), and scholars have proposed to dismantle the individual accounts. In 2010, the government promulgated the Social Insurance Law of the People’s Republic of China, omitting any mention of individual accounts.
Decade’s operation of the ‘social pooling plus individual accounts’ model demystified the imaginational merits of the individual health accounts. During the health reform in the 1990s, China had little knowledge of modern social policy, and administrative staff served as the backbone of health reform experts (Wu, Reference Wu2019; Interview no. 8; Interview no. 6) following the wisdom of ‘prioritizing the learning which could meet urgent needs’ (Wu, Reference Wu2003, p.283). Thanks to the explosive proliferation of social protection programs, China accumulated policy-making experience and built corresponding talent reserves rapidly. In the 2000s, well-trained scholars and think tanks played a major role in addressing the underperformance of individual accounts and proposing evidence-based policy solutions. According to official records, most fraud or illegal conduct related to social health insurance funds was associated with the individual accounts (Hua, Reference Hua2020). In 2006 alone, the individual accounts caused a fund loss or misuse up to 4.5 billion renminbi (RMB) (Wang & Li, Reference Wang and Li2015). By 2018, the balance for the urban employees’ individual accounts reached 714,442 million RMB, accounting for nearly 40% of the total fund balance of the urban employees (Hua, Reference Hua2020).
As the flaws of the individual accounts were revealed, the legitimation of bricolage was jeopardised. In 2019, the government issued an announcement, declaring the termination of individual accounts in the social health protection for urban unemployed and rural residents. Then, 2 years later, the social health insurance for urban employees embarked on transforming the individual-accumulated funds into a social-pooling fund for outpatient services.
Discussion
The bricoleur, as a mythical-thought-based action regime, dominated China’s health policy domain between the late 1980s and 1990s, mainly because of the urgent reform need and the lack of modern social security expertise. The main policy-makers were administrative staff who engaged in multi-tasking and undertook international travels to collect policy-making experiences. As their universe of instruments were closed, the rules of their game were ‘always to make do with “whatever is at hand”, that is to say with a set of tools and materials which is always finite and is also heterogeneous’ (Lévi-Strauss, Reference Lévi-Strauss1966, p.17).
Influenced by WB and ILO, China’s health policy-makers assembled social insurance and the individual accounts to substitute the existing working-unit-based labour health insurance. The two modern models, as constitutive units of myth (Lévi-Strauss, Reference Lévi-Strauss1966, p.19), were assembled to express the governmental political goal shift for social security, namely the ideational change from ‘egalitarianism’ to ‘fairness with considerable efficiency’. This policy hybrid was justified by a mythical-thought-based grafting argument. Individual accounts could target crucial health reform concerns and minimise the moral hazards. Culturally, individual accounts could appeal to the local culture and moderate the shock of Western modernisation. Although the opposing voices existed, few empirical data were available. It was widely believed that the advantages of the policy mix outweighed the disadvantages.
In a broadly diffused engineering ideology, bricolage is usually associated with second-best solutions, maladaptation, imperfection, inefficiency, incompleteness and slowness, but, as a matter of fact, in many design situations, it is the only thing that we can reasonably do when we are engaged in action. The outcomes of it are hybrid, imperfect, transient artefacts, which perhaps do not look very elegant, have lots of bugs and gaps and frictions and unusable components, but they do their job and can be improved. (Lanzara, Reference Lanzara1999, p.347)
In the 1990s, China had little knowledge about modern social policy and lacked the capability of engineering thought. As mythical thought dominated the health policy domain, bricolage, as the second-best solution, stood out. Drawing lessons from the reform experience of the 1980s, the basic elements of the old health provision structure were replaced with social insurance and individual accounts. Substituting elements implied that ‘each choice which is made will involve a complete reorganization of the structure’ (Lévi-Strauss, Reference Lévi-Strauss1966, p.19), and the functioning of assembled elements differed from bricoleur’s imagination. Adopting individual accounts privatised the social health protection’s funding structure and produced unexpected adverse effects, such as high fund balances and massive healthcare fund fraud. Since 2011, China has improved the policy hybrid by revising the individual accounts’ function scope.
Reflecting on the debate on the uniqueness of East Asian welfare regimes, the findings imply that the emergence of China’s welfare hybrid is strongly linked to the mythical-thought-based action regime, characterised by ideational grafting and practical substitution. Ideational grafting is based on learning activities, while practical substitution contributes to institutional instability. The two characteristics might explain the differences of opinion between Goodman and Esping-Andersen. Goodman argued for the distinctiveness of East Asian welfare models at the level of ideational grafting, while Esping-Andersen disagreed from the perspective of practical outcomesFootnote 12 . Their argumentation might be associated with the parable of the blind men and an elephant, as it fails to encompass a comprehensive view to analyse the uniqueness of East Asian welfare regimes and elucidate the intricacy of policy hybrids.
In connection to the contemporary discourse, the findings suggest that Lévi-Strauss’s analogy pair of ‘bricoleur’ and ‘ingénieur’ could help us better understand the travel of world culture, the process of global social policy-making and policy diffusion mechanisms. In line with the argumentation of Esping-Andersen, global social policy studies embrace the macro-phenomenon theory of world culture, underscore the Western cultural hegemony in social life worldwide (Meyer, Reference Meyer1980) and develop an international-organisation-focused approach to explain social policy diffusion (Deacon & Stubbs, Reference Deacon and Stubbs2013; Kaasch, Reference Kaasch2013). This framework is only partially plausible to China’s case, and integrating Lévi-Strauss’s insights might strengthen its explanatory power. The macro-phenomenon framework works out when interpreting the adoption of the German social insurance model. Its hypothesis of ‘war of positions’ (Kaasch, Reference Kaasch2013) could also make sense of China’s pension reform as WB and ILO contributed to the clash between the policy models (Hu, Reference Hu2012; Hu, Reference Hu2016). However, the framework encounters difficulty when attempting to explain the adoption of the individual account model in the health domain.
To further the inquiry, the lens of bricoleur is added. China adopted the policy hybrid by referring to a sub-set of the culture that had been available or collected. Western culture had a strong influence on China’s policy-making domain, but directly substituting the German social insurance faced cultural resistance, rendering it impractical. The finding implies that modern culture is disseminated globally as an exemplary model but also experiences the challenges of reformation. The lens of bricoleur also throws light on policy diffusion mechanisms by exploring the contents of the learning. ‘Bricoleur’ and ‘ingénieur’, driven by mythical and scientific thinking or knowledge modes separately, trigger social changes. The individual health accounts’ life course could mirror the rise and fall of the mythical thinking mode. As China developed its capability of scientific evidence-based policy-making, bricoleur took a back seat, and the innovative health policy mix has undergone a gradual exnovation process. The mythical and scientific thinking modes may potentially serve as the fundamental components of the learning mechanism.
Conclusions
In turbulent times, the management of policy innovation assumes greater significance. This article analyses China’s innovative health policy model to contribute to the existing literature on policy hybrids during globalisation, deepen our understanding of the policy learning mechanism, explore the exnovation process in policy management and call for a comprehensive view to examine the distinctiveness of East Asian welfare models.
The analysis identifies bricoleur as a crucial component of the learning mechanism, facilitating the differentiation between the learning and emulation mechanisms for policy diffusion studies. Given the limitations of available space, the detailed exnovation process is beyond the scope of this article. The demystification of bricolage involves an interplay between ‘bricoleur’ and ‘ingénieur’ action regimes within China’s case. An aspect worthy of exploring is the relation between policy feedback and policy learning. In the 1980s, the adoption of the individual health accounts was a strategy to smooth public resistance and lure people to accept the modernised health protection. In the last decade, as the malfunctions of the health saving accounts accumulated, the government endeavoured to remove the individual health accounts but encountered citizens’ opposition (He, Zhu & Qian, Reference He, Zhu and Qian2024). Policy-making is often caught in a dilemma, especially when confronting crises or urgent reform needs, and policy learning may involve intellectual failures. However, it might be premature to define the adoption of individual health accounts as a policy failure, and greater attention should be given to how China has been gradually revising and even terminating the individual accounts. Further investigation is needed to grasp the dynamics of driving forces behind policy innovation and exnovation to assist future policy design or decisions.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0047279425101190.
Acknowledgements
The author would like to thank the anonymous reviewers for their comments on an earlier draft of this article. Informed consent was obtained verbally before the conduct of expert interviews. Data are available on request owing to privacy or ethical restrictions. The fieldwork in China between August 2018 and December 2019 was supported by the Collaborative Research Centre (SFB) 1342, funded by the German Research Foundation (DFG, project no. 374666841 – SFB 1342). Special thanks go to Prof. Dr Tao Liu, Prof. PhD Karen Shire, Prof. Dr Anja Weiß, Prof. Dr Ute Klammer and German Academic Exchange Service (DAAD) for their important support for my research project at Duisburg-Essen University. To finish this work, the author also benefited from China’s National Social Science Foundation (project no. 22VRC182).
Competing interests
The author declares no competing interests.
Interview list
Interview no. 1: Interview in Wuhan, with a retired professor of health economics and health policy at Wuhan University, 2 October 2018
Interview no. 2: Group interview in Beijing, with a professor in social policy and social law in the School of Public Policy and Management at Tsinghua University, 22 September 2018
Interview no. 3: Interview in Wuhan, with a professor of health insurance and social welfare in the School of Public Administration at Central China Normal University, 28 September 2018
Interview no. 4: Interview in Beijing, with a professor of health policy and comparative welfare study in the School of Labour and Human Resources at the Renmin University of China, 21 August 2018
Interview no. 5: Group interview in Beijing, with senior researchers in the Social Security Laboratory of the Chinese Academy of Social Science, 29 August 2018
Interview no. 6: Interview in Zhenjiang, with a professor of health insurance in the School of Public Health at Jiangsu University, 25 March 2019
Interview no. 7: Group interview in Beijing, with leading researchers at the Chinese Academy of Labour and Social Security, 24 August 2018
Interview no. 8: Interview in Zhenjiang, with a professor of health insurance and health economics in the School of Management at Jiangsu University, 25 March 2019
Interview no. 9: Interview in Beijing, with a director of the Institute of the European Studies at the Chinese Academy of Social Sciences, 30 August 2018
