Social Protection under Authoritarianism : Health Politics and Policy in China Health Politics and Policy in China

Abstract

Why would authoritarian leaders expand social welfare provision in the absence of democratization? What are the distributive features and implications of social welfare expansion in an authoritarian country? How do authoritarian leaders design and enforce social welfare expansion in a decentralized multilevel governance setting? This book identifies the trade-off authoritarian leaders face in social welfare provision: effectively balancing coverage and benefits between elites and masses in order to maximize the regime’s survival prospects. Using government documents, field interviews, survey data, and government statistics about Chinese social health insurance, this book reveals that the Chinese authoritarian leaders attempt to manage the distributive trade-off by a “stratified expansion” strategy, establishing an expansive yet stratified social health insurance system to perpetuate a particularly privileged program for the elites while building an essentially modest health provision for the masses. In China’s decentralized multilevel governance setting, the stratified expansion of social health insurance is implemented by local leaders who confront various fiscal and social constraints in vastly different local circumstances. As a result, there is great regional variation in the expansion of social health insurance, in addition to the benefit stratification across social strata. The dynamics of central-local interaction in enforcing the stratified expansion of social health insurance stands at the core of the politics of health reform in China during the first decade of the 2000s. This book demonstrates that the strategic balance between elites and masses in benefit distribution is delicate in authoritarian and decentralized multilevel governance settings.