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Within a rapidly expanding global community, evolving economies and social structures challenge local governments to reform and revise historical practices in more supportive and efficient manners. New public sector management aligns explicit standards and objectives with a ‘hands on’ management technique dedicated to generating tangible outputs and improving efficiencies. Global leaders in such progressive policies recognize that convergence between nations as well as internal organisations continues to evolve public policy towards cohesive and translatable objectives. Recognizing the multinational variability inherent in public sector modernisation, the OECD (2003) reminds that oftentimes systemic differences and public transparency offer significant challenges to integrating such convergence methodology. Yet policy evolution challenges governing bodies to recognize the benefits of actively participating within the public sector and defining the nature of organisational compartmentalisation as well as establishing a participative role within a much broader multi-national enterprise.
Perhaps one of the most researched models of public sector management, the health care sector offers a challenging, yet essential participle to works programmes that are increasingly becoming a staple of humanitarian necessity. Goddard and Mannion (2004) recognized that governance systems evolve around a hybrid of vertical and horizontal methods, each imposing unique performance expectations on the constructs of public programmes. The former, a mode of authoritative control from a central body, enables dissemination of ideologies and performance expectations across a broad range of coordinated operations. More autonomous by nature and open to rapid evolution, under horizontal initiatives, local programmes are responsible for performance initiatives, oftentimes competing and collaborating with their counterparts throughout the process. Both the UK and China have integrated varied representations of such programmes as modes of reforming their health care initiatives. While similarities and natural convergence exist in practice and policy, the historic path towards improved public programmes has undergone dramatically divergent modes of operation. The following sections compare and contrast such evolution, recognizing the opportunities for future reform as health care reform becomes an increasingly volatile political topic.
In order to appropriately consider reform measures, government leaders must actively consider the benefits of decentralisation and potential for accountability protocol in spite of divergence. Davies, et al. (2005) challenge that it is important to the reform process to explore the advantages of increased competition prior to policy implementation; from this proactive, analytical standpoint, national leaders can actively direct their performance expectations in a result driven programme. Given the objectives of disggregation, performance contracting must integrate a multi-dimensional structure, one which becomes innate within corporate procedures, policies, and activities, and is regularly audited for compliance (Talbot, et al., 2000). Those nations who establish firm programme objectives prior to implementation will allow a variety of targeted studies, including convergence comparisons, future feasibility protocol, and concise results analysis. Within the UK reform system, the National Health Service (NHS) has been designed with performance measurement guidelines strictly integrated into its foundation. Specifically, the formation of Foundation Trusts, a type public-private partnership, has enabled regulation through achievement of performance objectives directly related to both economic and social expectations (Goddard and Mannion, 2004). A form of both vertical and horizontal control, such foundations provide for accountability along government sponsored programme lines as well as intra-network through their partnerships with other trusts. Talbot, et al. (2000) recognize that once agency control has been extended outside of the locus of governmental control, regaining oversight and returning operations to an internal government function is both difficult and oftentimes detrimental to the success of the programme. For China, however, this locus of control has presented a much more dire challenge, as redistribution of power to local authorities in the 1990’s represented a dramatic decline in health care coverage and a lack of social equity in opportunities. Historic challenges within the public sector reform initiatives are directly linked to a relaxed sphere of governmental control, one which is deeply seeded in a loss of democratic abilities, diverse and incongruous organisational formats, and coordination failures (OECD, 2004).
Perhaps one of the most integral but challenging objectives of public sector reform is that of economic benefit and appropriate balances throughout a developing system. Between 1978 and 1990, the Chinese government, realising that medical subsidies were limiting economic growth, reduced government spending from 32% to 15% of GDP revenue (Blumenthal and Hsiao, 2005). Palmer (2006) notes that in the UK, health care expenses currently account for around 7 percent per annum of English GDP and is expected to increase to around 8 percent over the coming five years. In spite of the dedicated capital flow, historic Chinese health care relied on an inefficient system which was eventually devolved to local governments and provincial leaders, dramatically adjusting the available financing within poorer rural areas (Blumenthal and Hsiao, 2005). In fact, recent data from the Chinese Ministry of Health demonstrates that spending per capita throughout urban areas is over 3.5 times that of rural areas, underling the subversive mechanisms of public sector divergence and reform efforts (Chinese Health Statistical Digest, 2005). Under the reformed UK NHS system, such deficiencies are idealistically reduced through a system of weighted capitation and demand-side reform (Department of Health, 2005). The long term objective is to impose efficiency standards on PCT’s in an effort to regulate the dispersion of funding across large geographical areas. In this way, both urban and rural participants receive equitable treatment and humanitarian interests are maintained in spite of social standing. The recent revision to the Chinese health care plan boasts similar principles, placing citizen services before profit and transitioning its national healthcare system to one of non-profit status (Juan, 2008). Unfortunately, a programme which is primarily reliant on tax surplus and participant fee payments will flounder within the overwhelming needs of a rapidly expanding global power.
One method that evolving governments have actualized rapid growth and economic stability is through public private partnerships and privatisation. Hsiao (1995) notes that given the radical shift away from governmental funding, market-oriented fee based systems became normative throughout China, thereby reducing the propensity of rural poor to pursue inoculations and more common medical treatments due to an overwhelming cost basis. The modern Chinese system purports a much more inclusive focus, challenging consumers to participate within the reform mechanisms and have a voice in government initiatives (China Daily News, 2008). Yet even under the reform measures within the NHS system, citizen vocalization remains a key point of debate, as a recent survey generated less than favourable results for the progress over the past several years. Ultimately, the challenge to the governing organisations is to allow a participative structure with accountability protocol for local commissioners who fail at their expected duties (Department of Health, 2008). Returning oversight to trusts and local authorities and expanding focus away from private finance initiatives and privately managed health care systems will continue to redress the challenges of performance achievement and social participation. Privatisation within the Chinese medical infrastructure has dramatically altered the quality and cost basis of medical services, undermining the needs of a financially burdened population, and evading governmental oversight due to limited performance evaluations and control mechanisms (Liu and Mills, 2002). Similarly, Dummer and Cook (2007) challenge that the Chinese regime moves towards a privatised and market-based economy of health care has led to inequity and inefficiency in the health service system, directly undermining the expected performance results achieved by international counterparts.
Considerations within public sector often revolve around government oversight and market partnerships which sustain broad focus objectives and offer progressive reform stability. One evolution of the NHS system which has a occurred as a result of the 2004 and 2006 white papers is the introduction of community health care, and most importantly, a predictive structure which integrates both local preventative care facilities with hospital services (Palmer, 2006). Exemplary of opportunism within private practice, within its historic format, Chinese practitioners have been encouraged to utilize more sophisticated methods of diagnosis and treatment (and by nature, more costly) as government subsidies actively reduce the cost of more fundamental treatments in order to extend medical opportunities to all classes of citizens (Wagstaff and Lindelow, 2008). Lakin (2005) reminds that within developing nations, natural inadequacies within the regime structure oftentimes encourage the integration of agency initiatives and public works management. An evasion tactic, agency integration offers an exodus from bureaucratic inefficiencies, thereby benefiting both social and economic development at a much more rapid and effective pace than government oversight can offer. Under the reform mechanisms set in motion in the NHS system, general practitioners (GP’s) are offered incentives for reducing the number of unnecessary hospital referrals and maintaining an appropriate geographic area for patient distribution (Palmer, 2006). Chinese reform mechanisms challenge practitioners to ensure appropriate distribution of the patient base, limiting hospital visits to those scenarios which require complex solutions not actionable at their local clinic or GP (Juan, 2008).
The nature of reform is one which continues to evolve as public interest and more efficient solutions become visible through experience and convergence. The OECD in their 2004 Policy Brief reminds that the impetus for public administration should be one founded on governance and not the narrowed and limiting principles of managerial oversight. This secondary nature defines the nature of policy implementation, and as public programmes are expanded to include private partnerships, governance becomes a fundamental utility which is directly linked to well defined performance categories. In the 1970’s over 90% of rural Chinese workers were covered by the cooperative medical system (CMS), most of who lived within 1.5 km from a township health centre (Dummer and Cook, 2007). Other schemes, the labour insurance scheme (LIS) and the government insurance scheme (GIS) covered the broad scope of other Chinese citizens in varied employ, ensuring that medical coverage was generally free and government subsidised (Dummer and Cook, 2007). Figures show that by 2003, 80% of China’s population (640 million people) lacked health insurance and even those who were represented by agency coverage were increasingly challenged to cover a higher percentage of their own medical expenses (Anson and Sun, 2002). Similar challenges have evolved throughout the reform process of the NHS system, as available resources are inefficiently distributed among the population resulting in increased waiting times and misdirection of care due to resource allocation. Researchers note that within the current NHS reform mechanisms, the vertical alignment of performance creates an inequitable system within which primary care trusts (PCT’s) are challenged to meet efficiency expectations outside of their capacity (Palmer, 2006).
Each representing a unique and politically charged challenge within the scheme of socio-economic expansion, the case studies of both the UK and China offer remarkable insight to the volatile and unpredictable world of public health care programmes. Ultimately, the nature of convergence, an informed collaboration across international borders will install comparable programmes within each system of operation; however, the nature of social and political environments ensures that public sector management techniques will remain unique to each governmental agency. Specific opportunities for policy reform do linger within each political structure, challenging conventional techniques and perceptions to evolve to meet public demand. First and foremost, the continued partnership with private enterprise will enable rapid evolution of public programmes for both nations in spite of their stages of development. By nature, the capitalisation of government programmes is dependent on the support of the public; recognizing this frailty, government partnerships will continue to offer modes of revenue generation without directly affecting a hypersensitive community. Secondly, equity across geographic areas is essential to the principles of supportive health care programmes. The failures within both structures are inherent in the definition of equity itself, in that it can no longer be taken as a literal term. Communities with larger populations must be availed of a larger budget for health care provision; whereas those communities who are more rural and of smaller makeup may receive a more limited budget, the opportunity for expanding such funding given varied annual trends should be readily available. Finally, global insight recognizes that preventative care is a means to life preservation and progressive health care practices which fundamentally improve health by active methodology. Both nations already recognize the substantial cost savings from reducing the number of practitioner visits through preventative awareness and care; therefore, revised programmes should place this educated perspective at the forefront of policy, actively ensuring that doctors and care providers are able to encourage such opportunities for wellbeing. While fully integrated convergence in a globalised community is an unrealistic ideal, the potential for collaborative development and multi-national partnership remains a worthy accompaniment to foreign policy. As health care programmes evolve and reform worldwide, the nature of humanity is one of wariness and rejection; through new public sector management practices, the potential for rapid assimilation and supportive expansion becomes a readily attuned mode of unprecedented participation.
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