Jane Duckett presents a vigorous argument for the need to understand the politics of the withdrawal of the Chinese state from the health care service after 1978, a hitherto under-researched topic in contemporary Chinese studies. This book identifies changes in the functioning of the health system as the outcome of a highly politicized and ideologically-driven retreat of the state. Duckett argues against the belief that health reform was a by-product of economic policies and, based on mainly official documents and speeches, identifies this as a form of politics of retrenchment, operating during the period from the 1980s to 2003. Politics of retrenchment is a concept introduced in the analysis of how, in European liberal democracies and post-communist states, the state withdrew from the responsibility of organizing and funding health care services and risk protection. This framework and the key factors and main characteristics of health policy-making are introduced in the first chapter, followed by a chapter on the Chinese health care system from the 1950s to the 1980s. The following three chapters discuss different areas of retrenchment, including budgetary retrenchment and the retreat from rural and urban risk protection. The conclusion highlights the main findings in a comparative perspective, clearly setting out the main characteristics of the Chinese state's retreat.
Underlying the argument set out in the book is an assumption derived from Duckett's framework. This is that decision-making at the top of the Party-state hierarchy is capable of creating capacity for implementation of proposed changes at lower levels. Institutionalization and funding generate stakeholders, and the conflicts between ministries, acting as “bureaucratic stakeholders,” and feedback of societal stakeholders (here, medical staff and patients), determine the outcomes and extent of retrenchment. In the urban case, Duckett convincingly argues that retrenchment from state responsibility was ideologically driven. This retrenchment was implemented through established administrative hierarchies in the health and other bureaucracies right down to the state enterprises and cities as owners of these enterprises. The result of reducing services and levels of risk protection of urban residents, a group of social stakeholders who were accustomed to taking welfare for granted, generated feedback resulting in a fear of social unrest on the part of government and a need for the reintroduction of a degree of social security.
However, I am not convinced that this central-level focus is sufficient to explain the collapse of the Cooperative Medical System (CMS), the basic programme of risk protection in the countryside. Duckett argues that the CMS collapsed because the health ministry refrained from support after 1982 when the ideological wind turned against this leftist policy of the Cultural Revolution. Unafraid of being punished (p. 68), there was an incentive (p. 97) for local levels to withdraw their support and to stop organizing farmers into local schemes, resulting in the rapid collapse of the CMS.
This framework, with its implicit top-down implementation logic, is limited in a decentralized policy arena. Even during the Cultural Revolution, when administration by the Ministry of Health had broken down, the CMS continued to be operated and funded by commune and brigade cadres. Duckett describes this administrative framework and factors giving rise to autonomy of the collectives, but she does not readjust her framework on this basis. Centrally planned and orchestrated Party campaigns relating to the CMS, hygiene and health prevention work (which do not get a mention in Duckett's book) replaced state administration to overcome the distance between the central state and the collectives. The detailed analysis of weak state capacity and conflict between ministries presented in the case of the urban sector seems to be absent in the discussion of rural areas. This leaves the decision of the Ministry of Health at the central level to retreat from health provision as the exclusive explanation of changes at the local level. This is of doubtful explanatory power. Firstly, the CMS had already collapsed in some areas during the Cultural Revolution. One has to ask why local leaders should be more afraid to continue implementing the CMS in 1981 than during the Cultural Revolution, especially if the argument relies exclusively on the direction of the Minister of Health without any triangulation from other, local, sources. Furthermore, it is assumed that the CMS collapsed immediately following the minister's statement, whereas this must remain under debate, given that yearly statistics for CMS coverage are simply not available (p. 6).
Disaggregating the state into different levels would allow one to question the argument that fiscal crisis and the impact of the minister's opinion were the cause of state retreat at local levels.
This work shows how ideological positions in the Ministry of Health, and not central state budget constraints, can play a dominant role, especially in authoritarian polities with weak social stakeholders. Despite the criticisms raised here, the author should be commended for taking a significant step forward in this direction.
