Sub-National Welfare Regimes and Driving Forces: Understanding Health Poverty Alleviation Policy in China

Background/Purpose: China’s triumph over absolute poverty in 2020 has sparked investigations into the complexities of its poverty alleviation policies. Given the significant administrative decentralization and uneven economic development across the country, policymaking at the prefectural level demonstrates notable discretion. While previous studies have explored local variations of China’s social safety net program, specifically the social assistance program, there are limited comprehensive analyses of other domains of poverty alleviation policies, such as healthcare and education. Illness is a leading cause of poverty in China, and the government has made substantial efforts to develop pro-poor health policies. This study focuses on health poverty alleviation policy, which was a pivotal component of China’s previous poverty alleviation campaign. We aim to answer the following research questions: What are the sub-national welfare regimes of local health poverty alleviation policy? What factors drive variations in these regimes?

Methods: We established a comprehensive policy database by systematically coding the content of the policy document Poverty Alleviation Plan for the 13th Five-Year Plan period (2016-2020) across 22 provinces and 78 cities. To capture the local policy variations, we perform the cluster analysis based on city-level policy scores regarding both policy domains (i.e., health financing, health service delivery, and public health), and overall policy attributes (i.e., comprehensiveness, magnitude, and adaptability). Next, we conduct multinomial regression to analyze the determinants of varied local regimes. Determinants are political factors, including the top-down mandate of the provincial government, fiscal dependency, and characteristics of city political leaders (i.e., age, education, gender, and tenure), and social risk factors (i.e., the incidence of individual catastrophic health spending, life expectancy, and local healthcare resources). We also include a series of control variables, such as GDP per capita, previous welfare generosity, and population size. All determinant variables have a one-year lag.

Results: We find most cities (65%) exhibit a balanced policy magnitude across three policy domains, with a few cities emphasizing more financing (11%), delivery (11%), and public health (13%), respectively. Regarding policy attributes, 69% of cities emphasize all three attributes. A few cities (17%) have a higher level of policy adaptability than the other two attributes, while some cities (15%) prioritize comprehensiveness and magnitude over adaptability. Multinomial regression analyses reveal that the top-down mandate of the provincial government, fiscal dependency, and gender and tenure of local politicians have a more significant impact on local welfare regimes compared to social risk factors.

Conclusions and implications: This study contributes to the investigation of the sub-national variations in pro-poor health policy within an administratively decentralized context. Our findings underscore the nuanced sub-national variations in China’s health poverty alleviation policy, with political factors as primary drivers of sub-national welfare regimes in anti-poverty efforts. Policy implications and policy coding framework derived from this study will also be valuable for future pro-poor health policy research in China and beyond.