Implementing and innovating : local governments in the development of China's new cooperative medical scheme

From 2002-2003, development of China's New Cooperative Medical Scheme (NCMS), a rural health insurance programme, was initiated based on an 'experimental' process of piloting and roll-out. The NCMS has developed rapidly since then: from limited coverage and funding, it has been extended nationally and funding has increased dramatically. Most analyses of the scheme focus on its impact on users' health seeking and spending, paying less attention to the policy and its development. Much literature on central-local relations in China foregrounds questions of power and the centre's ability to enforce sub-national policy implementation. The NCMS, however, shows a policy principally run at the county level, under which counties have a responsibility both to implement the scheme and to develop workable local policy within a loose overall national policy framework. This gives a degree of freedom, or discretion, in operation of the scheme. This study argues against seeing localities as simple implementers of pre-cast central policy, and argues for supplementing this with an understanding of the role of counties as frontline interpreters and developers of policy, and as innovators within supra-local policy frameworks. It examines the structuring of scheme implementation alongside ways counties operate within the overall NCMS framework, the degree of discretion they have, and the possibility and importance of local generation of policy, policy mechanisms and models. This gives a view of local practices and production of institutions on the periphery of the state policy making apparatus, where local diversity and implementation often run ahead of central policy. Based on county-and province-level fieldwork, this study examines the origins and systemic basis of selected county reforms, their systemic relevance and impact, and shows local practices as part of a loosely structured 'conversation' in which multiple levels of government play differentiated roles in a complex and ongoing process of reform.