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Unorthodox approaches to participation in authoritarian regimes : the making of China's recent healthcare… Kornreich, Yoel 2011

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Unorthodox Approaches to Public Participation in Authoritarian Regimes: the Making of China’s Recent Healthcare Reforms  by  Yoel Korneich  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in The Faculty of Graduate Studies (Political Science)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  October 2011  © Yoel Kornreich, 2011 ii  Abstract In recent years, non-democratic regimes have introduced a host of participatory forums. This paper asks why, given the absence of binding constitutional or institutional designs, authoritarian governments introduce, at their own initiative, participatory forums? To respond to this question, the paper suggests three theoretical possibilities: fragmented authoritarianism, enhancing legitimacy and information-gathering. Looking at the drafting of China’s recent healthcare reforms--where the government enacted various forums of participation--the paper tests these theories. Its findings indicate that these theories are not mutually exclusive, as each could explain the causes for the introduction particular participatory forums. This paper argues that this analytical framework could extend beyond the scope of China’s healthcare reform, and be applied to other episodes of policymaking both in China, and other non-democratic regimes.  iii  Preface This research was approved by UBC Behavioral Research Ethics Board. Number of ethics certificate: H11-01366   iv  Table of Contents Abstract ...................................................................................................................................... ii Preface ...................................................................................................................................... iii Table of Contents ....................................................................................................................... iv Acknowledgements .....................................................................................................................v Introduction ............................................................................................................................... 1 Chapter 1: Literature Review ....................................................................................................... 3 Chapter 2: Theory and Observable Implications ............................................................................ 7 2.1 Theoretical Frameworks ................................................................................................. 7 2.2 Observable Implications ................................................................................................. 8 2.2.1 Timing ................................................................................................................ 9 2.2.2 Selection of Participants ....................................................................................... 9 2.2.3 Official Discourse on Participation ....................................................................... 11 2.2.4 Extent of Media Coverage .................................................................................. 12 2.2.5 Feedback Generated Through Participation .......................................................... 13 2.2.6 Government Response to Feedback ..................................................................... 13 Chapter 3: Testing the Theories .................................................................................................. 16 3.1 Participation of Expert Intellectuals ............................................................................... 16 3.2 The “Two Meetings”: Elite Deliberation ........................................................................ 23 3.3 First Online Portal: Indirect Participation of Professionals ............................................... 27 3.4 Face to Face Interaction between Non-Elites and the Government .................................... 30 3.5 Second Online Portal: Indirect Public Participation ......................................................... 32 3.6 Mass Media: Amplification of the Online Portal ............................................................. 37 Conclusion .............................................................................................................................. 43 Bibliography ............................................................................................................................ 49   v  Acknowledgements I am first and foremost indebted to my supervisor, Alan Jacobs. For a newcomer into the discipline, Alan’s course on qualitative methods has been an invaluable introduction into the craft of conducting research in political science. Alan also greatly assisted me in conceptualizing an analytical framework for my research, and throughout my work on this thesis, he has given me indispensable feedback. I am most grateful to Mark Warren, whose unconventional teaching of political theory and revisionary approach to the study of Chinese politics were a great source of inspiration for me in my graduate work. I am also thankful to Lisa Sundstrom and Anjali Bohlken for introducing me to the nascent literature on participation in authoritarian regimes. I would also like to thank my fellow graduates at the department, especially Han Zhen (Arc), Pascale Massot and Daniel Westlake, for providing me with an intellectually-engaging and supportive environment. Finally, I would like to thank my parents, Liora and Avi Kornreich, for their love and unrelenting support. And, my partner, Lisi Feng, for her patience and delicious Cantonese soup. 1  Introduction In recent years, non-democratic regimes have introduced a host of participatory forums. A variety of participatory forums enabled broad representation of diverse groups within society, and allowed for divergent segments of the population, as well as interests groups, to publicly air their concerns with respect to issues that directly affect their lives and livelihood. These participatory forums had considerable impact over policymaking processes.   Broad public participation is common in democratic systems. Ethos of citizens’ sovereignty and government’s accountability underwrite both legal and institutional arrangements that allow for participation and expression of ideas and interests. These arrangements also mandate democratic governments to credibly commit to responding to citizens’ demands.  Non-democratic regimes, however, lack the ideational and institutional infrastructures that underlie public participation and government responsiveness in democratic systems. Citizens’ right to participate in the drafting of policies that directly affect their lives and government commitment to respond to the citizens’ concerns are not anchored in binding constitutional or institutional mechanisms.   Participatory forums under authoritarian systems may not be identical to democratic regimes, as authoritarian regimes control the scope and domain of participation. Yet, scholarship on participation in authoritarian regimes, has not fully explored why, given the 2  absence of binding constitutional or institutional designs, authoritarian governments introduce, at their own initiative, participatory forums?  In trying to answer this question, this paper will begin by critically assessing the extant literature on participation in non-democratic settings. It will then suggest three possible theoretical frameworks--Fragmented Authoritarianism, enhancing legitimacy, and information-gathering--to explain an authoritarian government’s reasons for encouraging public participation. These theories will be tested according to seven distinct indicators. Having outlined the theories and indicators, this paper will proceed to testing these theories through a case study--the drafting process of China’s recent healthcare reforms, where the government introduced a variety of participatory forums. The paper will conclude with a discussion on the applicability of insights gained from this case study to other policymaking episodes in China and other non-democratic systems.   3  Chapter 1: Literature Review To approach these questions, the paper will first examine the extant literature on participation in authoritarian systems. It will critique some of the assumptions underlying studies on the prospects of political change in China, and will, then, capitalize on insights gained from a nascent literature on participation in China and other non-democratic regimes. Having reviewed this literature, this paper will define what it seeks to contribute to our knowledge of participation in authoritarian regimes.  In discussing China’s future, Minxin Pei (2006) conceptualizes the ‘trapped transition’ paradigm. According to Pei, China’s political elites are reluctant to pursue political reforms, as they fear that these policies would erode their hold on power. The Chinese Communist Party, as Pei argues, may introduce participatory practices, but these practices would be construed and superficial. The lack of political reform, Pei posits, would vitiate the ability of the state to gain the support and collaboration of the populace in maintaining economic development, and this would eventually result in economic stagnation, and an erosion of state capacity. Unlike Pei, this paper argues that recent participatory practices introduced by the Chinese government are substantial. These practices may enable China’s authoritarian regime to avoid the predicament of ‘trapped transition’, and allow it to mobilize the populace for the task of economic development.  Contrary to Pei, there is also a literature on democratization in China. Authors within this paradigm tend to focus on two possible causal mechanisms. Bruce Gilley (2004) looks at 4  elite-driven democratization from the top, contending that a reform faction within the Chinese leadership is likely to promote democratization. Other scholars claim that democratization would commence at the grassroots level, through the introduction of democratic procedures, such as village elections, and later spread to the top levels of government (Manion, 1996; Jennings, 1997). Unlike this strand of literature, I contend that since Chinese elites do not opt for democratization these two causal mechanisms are unlikely--they would neither initiate democracy at the center, nor would they allow village democracy to spread beyond the grassroots level.  In my research, I attempt to show that in order to understand current political changes in China we need to look at participatory practices introduced by the government, rather than at grassroots or elite level democratization.  Instead of searching for causes that would generate a democratic transition, other scholars tried to show that changes within the existing system induced more participation. The rise of a pluralized, commercialized media has allowed new actors--journalists, NGOs, low ranking officials--to influence policymaking (Mertha 2008). Growth in the business sector has led to the emergence of business lobbying vis-à-vis the government (Kennedy 2005). While concurring with the insights from these studies, this paper will attempt to explore a different form of participation. Rather than looking at participation that originates from below, this paper examines participation that is initiated by the government. 5   The argument of this paper resonates with an emerging literature on participatory practices in non-democratic regimes. This literature contends that participation in non-democratic regimes is employed for the accomplishment of two key goals. First, these regime elicit participation in order to garner popular support and cooperation with the regime, while, at the same time, containing contentious actions and co-opting potential opposition (Gandhi 2008; Richter 2009; 41; Rodan and Jayasuriya 2009). Second, authoritarian governments utilize participation not only in order to gain support, but also as a “public feedback mechanism” (Evans 2010; 18), in order to “attract substantive input from social organizations into the policy process” (Richter 2009; 61). Like these studies, this paper will also suggest two theories for explaining the causes for introducing participation: 1.) enhancing legitimacy--that is, generating popular support for the government and its policies; 2.) using consultation in order to gather technical information conducive for the refinement of policymaking processes. By testing these theories, this study will attempt to offer two complementary frameworks to the prevailing paradigm in the study of policymaking in China--Fragmented Authoritarianism (FA) (Lieberthal and Lampton 1992; 8-9; Lieberthal and Oksenberg 1988; 137-142; Mertha 2008; 2). It will show that FA alone cannot explain some of the key features of policymaking in contemporary China.  Most recently, He Baogang and Mark Warren--in a pioneering article on new modes of participation in China--have coined the term ‘authoritarian deliberation’. The authors aver that deliberation is possible not only in democratic countries, but also in authoritarian 6  systems. Their argument is that the Chinese government introduces a host of both deliberative and consultative practices in order to garner legitimacy, gather information and reach consensus (He and Warren 2011; 274). In many ways, the objective of this paper is to complement the argument first laid out by He and Warren. Whereas their analysis has been primarily theoretical, in this paper, I hope--through focusing on the specific case of participation in China’s healthcare reform--to empirically test their argument.    7  Chapter 2: Theory and Observable Implications 2.1 Theoretical Frameworks To uncover the causal mechanisms that induce participatory practices, this paper will examine three distinct theoretical possibilities: ‘fragmented authoritarianism’, ‘enhancing legitimacy’ and ‘information-gathering’. Afterwards, it will outline their observable implications.  Since the late 1980s, FA has been the dominant paradigm in the study of policymaking in contemporary China. This theoretical framework assumes a disjointed structure of authority within China’s bureaucratic system, along both vertical and horizontal lines. According to FA, the processes of devising and implementation of policies are subject to constant bargaining between contesting administrative units with rivaling interests (Lieberthal and Lampton 1992; 8-9; Lieberthal and Oksenberg 1988; 137-142; Mertha 2008; 2). This paper assumes two possible causal links between FA and participation. First, certain parties within the bureaucracy may utilize participation in order to gain the upper hand in the bargaining process--through the  solicitation of participants whose positions are likely to be consonant with their own. Second, participation of external actors might be a last recourse embraced by all parties within the bureaucracy after failing to arrive at a consensus. All parties may hope that actors neutral to the bureaucratic conflict could formulate a solution that is agreeable to all contending bureaucratic factions. 8   While in FA intra-bureaucratic disagreements would be the source of participation, a second theory would view an authoritarian government’s endeavor to enhance its legitimacy as the core motivation for promoting participation (Guo 2010). According to this theory, participation would enable a non-democratic regime to create a semblance of citizens’ participation, and furnish the government with an opportunity to publicize its responsiveness to the people’s concerns. In this manner, the regime would strengthen its popular base of support.   Contrary to enhancing legitimacy, a third theory sees the need to gather information as the impetus for eliciting public participation. Rather than a ‘window dressing’, or a populist device to gain support, the primary purpose of these participatory practices, according to this theory, would be to establish a channel through which an authoritarian regime would derive feedback from the populace, and utilize it to refine and adjust policymaking processes. The motivation for establishing participatory forums, as this theory postulates, would be to accomplish efficiency in the government’s work. 2.2 Observable Implications  To test each of these three theories, this paper will explore the observable implications in relation to seven indicators. While the first indicator refers to direct evidence on the origins of participatory practices, the other indicators are all related to the design of each of the participatory forums: timing, selection of participants, official discourse on participation, extent of media coverage, type of feedback generated through participation, and 9  government’s response to this feedback. For each of these of indicators, the juxtaposition of the distinct observable implications for each of the three theories would furnish us with the analytical tools for identifying the causal mechanisms inducing participation. While attempting to lay out unique observable implications for each the theories, this paper does not rule out the possibility that these theories may not be mutually exclusive. 2.2.1 Timing  Examining the timing for the enactment of the various participatory forums, at different points during the policymaking process, one could draw conclusions on the government’s goals.  If participation would be introduced right after contending bureaucracies failed to reach an agreement, then the proper analytical framework would be FA.  If participation would start after the government finalized the policy plan, then we could ascertain that it is driven by the quest for legitimacy. Participation would merely be a ‘window dressing’ device advanced in order to legitimize a policymaking process from which the citizens were excluded. Yet, for gathering information the government would introduce participation prior to devising the policy plan, so that feedback generated in the process could have a substantial impact on the policy. 2.2.2 Selection of Participants  As for the selection of participants, in the case of FA, the composition and number of the actors invited to attend would be limited. If a certain faction exploits participation in order to get the upper hand in the bureaucratic competition, we would see the exclusive selection of 10  participants whose positions are in agreement with this faction. If participation is the product of a joint effort by all bureaucratic parties to move away from an impasse in the bargaining process, then they would invite outside actors who are assumed to be neutral to the bureaucratic contestation. Or, in selecting participants, they would attempt to have a balanced composition of participants, so that the positions of all bureaucratic factions would be represented. If participation is promoted in order to resolve bureaucratic disputes, it is likely that these bureaucracies would solicit the advice of expert intellectuals, as their expertise in the policy issues could assist the bureaucracies to formulate guidelines for a compromise.  Whereas in FA the participation circle would be limited, in the case of legitimacy, representation would be the key. Since the objective of participation is to gain the public’s support, rather than input, the government would seek to demonstrate that diverse social groups and stakeholders are all attending the participatory forums, and that their opinions are being considered.  Contrary to ‘legitimacy’, in ‘information gathering’ representation would not be a concern, since the government does not intend to utilize participation for public relations ends. But, while representation is not central to information gathering, the principle of inclusion is important, as some feedback from the general public could generate information which is indispensable for the refinement of the policymaking process. Yet, while encouraging feedback from the general public, the government would primarily target participants who are able to provide informed, technical advice on policymaking. As in FA, 11  this would include expert intellectuals. But, in addition to them, the process would also consist of practitioners and professionals who posses knowledge and experience that are relevant to particular policy issues. 2.2.3 Official Discourse on Participation  In FA there would be little official discussion on the objectives of the participation forum as it is intended to solve intra-bureaucratic conflicts, rather than polish the government’s public image. The discourse is expected to be neutral, and simply contain information about the opening of this outlet for participation.  If the government’s objective in initiating participation is to garner legitimacy, rather than resolve internal disagreements, then, the introduction of participation would be accompanied by a government endeavor to utilize it as a public relations stratagem. The government would exploit participatory practices to extensively publicize its benevolence, empathy and responsiveness toward the populace. And, in inviting the public to participate, the government, rather than asking for feedback on specific issues, would simply urge the public to express their opinions.    Contrary to legitimacy, in information gathering, the official promotion of participatory practices would not be accompanied by rhetoric on the benevolence and responsiveness of the government--as in FA, this would be a neutral discourse informing the populace about the enactment of a participatory forum. The government’s announcement on participation, contrary to legitimacy, would be stated in a more specific manner, inviting 12  participants to respond to particular policy issues, with which the government is grappling, rather than expressing their general opinions. 2.2.4 Extent of Media Coverage  The extent of media coverage of participation could also enable us to identify the relevant theoretical framework. In FA, it is possible that the attempt of different factions within the government to use the media as leverage in the bureaucratic struggle would eventually contribute to increased media attention to the participatory forum. But, if the enactment of participation is an outcome of a joint effort of the rivaling factions, in order to disentangle a gridlock, then the extent of media coverage of the process would be low, as these bureaucracies seek the suggestions of expert intellectuals, and have little interest in having the general public involved in the process.  If the government intends to utilize participatory practices for enhancing legitimacy, then we would expect to see extensive coverage of the participation process, as the government would exploit it to communicate to the populace its concern for their opinions. For ‘gathering information’, as in the case of legitimacy, we would expect to observe some effort to publicize the introduction of participatory practices, in order to inform the public and elicit attendance. Contrary to legitimacy, however, the degree of media coverage would be smaller, as the mainstay of the process would be consultation with expert intellectuals and professionals. 13  2.2.5 Feedback Generated Through Participation  If FA is valid, the suggestions raised in the participatory forums, prompted by fissures within the bureaucracy, would address the concerns of these bureaucracies. Whether the participants’ proposals tilt toward the positions of specific factions within the government, or they represent a neutral stance, they would all focus on the key issues of dissension, and suggest strategies to solve them.  In cases where the impetus for participation is legitimacy, we would see brief and cursory feedback. Since the purpose of participation is to publicize that it takes place, rather than generate input, the government would design it in manner that elicits predictable responses that do not constitute a challenge to the government’s policy plan. This feedback may contain the expression of grievances with respect to certain well known problems within the system, yet it would not include practical proposals on how to address these issues. In the case of ‘information gathering’, however, we would expect to see concrete and detailed policy suggestions on how to improve the policymaking process. 2.2.6 Government Response to Feedback  The government’s response to the feedback would vary in accordance with its goals in initiating participation. If it was triggered by FA, the government would embrace either suggestions that entail a compromise between contending bureaucratic parties, or those that resonate with the stances of the strongest bureaucratic faction. 14   In case of legitimacy, the government’s response to feedback would primarily target the general public, rather than address the issues which are at the heart of the bureaucratic controversy. We may see the government boasting about its willingness to listen to the public, though no substantial public input would be absorbed. Or, if the government decides to respond to the people’s suggestions, it would endorse populist measures that intend to pacify a large group of the population, so as to win the public approval of the policy. For ‘information gathering‘, however, we would observe government‘s incorporation of technical suggestions, which could lead to improved policymaking outcomes, and which would not necessarily appeal to a large group of the populace.  This section outlines the observable implications unique for each of these theories. To establish that FA is valid, would require that: participation would occur in the aftermath of a bureaucratic gridlock, the number of participants would be limited, government discourse on it would be neutral and the extent of media coverage would be minimal, and both the feedback generated and government response to it would refer to issues that are at the heart of the bureaucratic contention. In legitimacy, however, participation would take place at a late stage in the policymaking process, the selection of participants would emphasize representation, the official discourse would underscore government responsiveness and media coverage would be extensive. The content of the feedback would be cursory and predictable, and the government may respond to it in a populist fashion. For “information gathering”, we would expect that participation would commence at an early phase in the policymaking 15  process, and that participation would be limited to experts and professionals, though there would be limited space for inclusion of the general public. Official discourse would be neutral and the extent of coverage would be smaller, compared to “legitimacy”. The feedback generated, nevertheless, would contain substantive policy suggestions, which would later be absorbed by the government.  16  Chapter 3: Testing the Theories To test the applicability of each of these distinct theories to participatory practices in authoritarian regimes, this paper will examine the particular case of the making of the recent rounds of healthcare reforms in China (2006-2009). In the course of drafting this policy, the Chinese government introduced various participatory forums: consultation with expert intellectuals and international organizations, discussions and debates at the “Two Meetings” of China’s National People’s Congress (NPC) and China People’s Consultative Conference (CPPCC), two online participation portals open to the public (2006 and 2008), media interviews with key stakeholders, and meetings between government leaders and representatives of diverse groups within society. Each of these forums is a distinct case, and the government’s reasons for introducing each of them may be different. In addition, there may be more than one reason for the introduction of these forums. To explore the causes for initiating each of these participatory forums, this section will now examine each case according to the aforementioned indicators, and draw conclusions in regard to the theoretical frameworks that apply to the each of the particular instance of government-sponsored participatory forums. 3.1 Participation of Expert Intellectuals  This paper would first probe into the case of participation of expert intellectuals and international organizations in the drafting process. The participatory practices involving a 17  small elite group commenced in March 2007, when the Healthcare Reform Coordinating Small Group--the inter-ministerial body vested with the responsibility for devising the blueprint for reform--invited outside actors to submit blueprints for the healthcare reform. Among these organizations were: Beijing University, the State Council Research Development Centre (DRC), Fudan University, WHO, World Bank and McKinsey & Company. Later, the government also solicited Beijing Normal University for a blueprint, and Renmin and Tsinghua universities submitted proposals at their own initiative. A tenth proposal, which represented the views of the medical profession, was eventually solicited from Zhongshan University.  Looking at the origins of this opening the drafting process for participation of outside actors, we can see that FA precipitated this outcome, after negotiations inside the Healthcare Reform Coordinating Small Group among the key stakeholders in reform--Ministry of Health (MOH), Ministry of Human Resources and Social Security (MOHRSS), Ministry of Finance (MOF) and National Development and Reform Commission (NDRC)--reached a deadlock.  The primary source of disagreements was the method of funding for public hospitals. As the government department responsible for the management of hospitals, the MOH pushed for a supply side solution, where the bulk of government financing would be directly transferred to  healthcare providers. Being the ministry in charge of social security, the MOHRSS resisted it, and advocated a demand side solution, where the majority of government funding would be invested in health insurance. The MOF and NDRC aligned 18  with the MOHRSS, as they believed that a demand side solution, which would induce competition among healthcare providers for insurance compensation, would prompt fiscal efficiency and lead to reduced healthcare costs (Du and Zhang 2007; Zhu 2011).  The same divisions also persisted in the inter-ministerial controversy over the management of public hospitals. The NDRC, MOF and MOHRSS opted for a separation between the MOH and direct management of public hospitals, so that the MOH would be in a position to oversee the work of hospitals. These departments were also supportive of the entrance of private capital into public hospitals, and the granting of a status of an independent legal person to public hospitals. But, while these departments thought that these measures would increase efficiency and prevent the waste of public resources, the MOH opposed these policies, which would diminish its authority. Instead, the MOH suggested a system of complete integration between government administration and hospitals (shouzhi liang tiaoxian), in which hospitals’ expenses would be covered by the government, and the former also would remit their revenues to the latter. In order to protect its control over the healthcare system, the MOH also opposed privatization of public hospitals (Du and Zhang 2007; Hsiao and Yip 2008; Wang 2009d; Yang 2008; Zhu 2011).  Media reports, as well as both English and Chinese language scholarship--which are based on interviews with government officials or scholars attending this process of government consultation--all confirm that in February 2007 the government decided to turn to outside actors as a consequence of these disagreements, after the government departments 19  had not been able to arrive at a consensus (Du and Zhang 2007; Thompson 2009; 59; Xinhua 2008a; Zhu 2011). FA here was clearly the origin of this participatory practice.   The composition of participants also indicates that FA was the cause for opening the intra-government policymaking process to outside actors. The circle of consultants was quite limited, and the participants were a small group of elite intellectuals from China’s top universities and renowned international organizations--experts in the field who may have the capacity to disentangle issues of deep disagreements inside the bureaucracy. It seems that the selection of consultants was motivated both by an attempt to arrive at a balance between the contending factions, and, at the same time, to solicit neutral views that may be acceptable to all parties. The consultation included the proposals of Fudan University, Beijing University (led by Li Ling) and DRC, which resonated with the positions of the MOH, and the proposals of Renmin University Beijing Normal University and Beijing University (led by Liu Guo’en), which shared some commonalities with the stances of the MOHRSS, MOF and NDRC. Yet, this consultation also included outsiders with views that did not necessarily align with the positions of particular government departments--WHO and World Bank. This evidence demonstrates that the selection of participants was motivated by FA--the government selected a small of group experts, hoping that they would be able to suggest ideas on how to overcome bureaucratic disputes.  Official discourse on this consultation was quite succinct. The media briefly reported about it, and the blueprints have never been made public. Only the key principles of each 20  proposal was reported (Sohu 2008c). There was no attempt to utilize this consultation for conveying any particular message to the public. This lack of a distinct discourse could ascertain that the purpose of this participation forum had nothing to do with engaging the public--it was enacted in order to settle intra-government disputes.  In spite of the neutral discourse on this process, throughout the drafting period, the Chinese academics selected for the consultation process attended a high profile media debate on China’s healthcare reform--an indicator that may negate FA. Yet, the extensive coverage of this debate was not the direct result of FA. The debate among intellectuals started before the government initiated this participatory practice in March 2007. In July 2005, the State Council’s Development Research Centre (DRC) published a report which blamed the marketization of healthcare services for the vulnerabilities of China’s healthcare system. This report elicited critique from intellectuals advocating marketization of healthcare services, and ignited a media debate. The fact that the key figures in this debate--Li Ling (Beijing University), Gordon Liu (Beijing University), Gu Xin (Beijing Normal University) were later solicited by the government for consultation may have contributed to increased media interest in their views. But, even if FA, here, led to an intensification of the media debate, it was not the primary cause of it. Also, there is no evidence that specific factions within the government exploited the media appearances of particular intellectuals to push forward their agenda. The extensive media coverage of the consultation process could not be directly attributed to FA. 21    In fact, the debate on healthcare reform was part of a broad elite wrangle on the trajectory of China’s development. Concomitantly to the debate on healthcare reform, there were also other public debates on the restructuring of China’ s State Owned Enterprises and the Property Law, where the social implications of previous market reforms were criticized (Li 2010; Zhao 2008). In the particular debate on the healthcare reform, the ideological differences also represented the bureaucratic fault lines--the positions of the proponents of increased government management of healthcare services were consonant with the preferences of the MOH, whereas the views of the advocators of marketization of health services coincided with the stances of the MOHRSS, MOF and NDRC. Yet, the intellectual debate represented a deep ideological struggle inside China’s elite which transcended bureaucratic interests. This debate was not a direct consequence of FA.  While the extensive media debate is not consistent with the observable implications of FA, the feedback generated from this participatory point to bureaucratic fissures. The core of the majority of the proposals submitted to the government focused on macro issues which were of concern to the contending bureaucracies--methods of government funding of healthcare services, and management of public hospitals.  The government’s response to feedback from this consultation reflected the outcome of the intra-bureaucratic competition. The faction of the MOHRSS, MOF and NDRC prevailed, as the majority of government funding for healthcare reform--two thirds--was funneled toward a demand side option, while one third of it toward s supply side (Sohu 2009a). The 22  feedback that was absorbed into the policy plan reflected suggestions that were favorable to the winning faction. The draft endorsed the strategies for encouraging private capital to enter public hospitals ( 2009), which was first suggested by the proponents of marketization among the expert intellectuals. The government’s response to the blueprints represented the outcome of the bureaucratic competition.   Having demonstrated that the solicitation of expert intellectuals was driven by FA, we still cannot dismiss the possibility that the need for information gathering also prompted this call for intellectuals to submit their proposals to the government. The policy issue on which the participants were consulted--a comprehensive overhaul of China’s healthcare system--is an intricate endeavor that bureaucracies alone may not always be equipped with the appropriate technical knowledge. This consultation took place at an early phase in the drafting process, indicating that input from this process could have had a potential for having a substantial impact over the policy plan. The small number of participants included distinguished specialists who may be able to disentangle some of these complexities. If we examine the feedback generated in the process, as well as the government response to it, we could see that some of the suggestions raised by the WHO, such as the construction of an infrastructure of grassroots clinics and the a system of basic medicines (Thompson 2009)--which were not directly related to issues of bureaucratic contention--were endorsed in the final draft of the healthcare reform. Moreover, some of the recommendations from the tenth proposal by Zhongshan University, which did not address the primary concerns of the 23  bureaucracies, were also absorbed into the new policy. In particular, the new reform stipulated the granting of special benefits to medical doctors willing to work in grassroots clinics, and also setting the rate of insurance compensation for outpatient services at grassroots clinics at a higher level than other hospitals (Xinhua 2008e). This shows that in addition to FA, the consultation process was prompted by the government’s need for technical advice on an extremely complex policy issue.  The possibility that this consultation was motivated by the search for legitimacy can be ruled out. The government included here a very small elite circle, while the public was excluded from participation. And the government never exploited this forum to publicize its responsiveness to the populace. 3.2 The “Two Meetings”: Elite Deliberation  In addition to soliciting the proposals of expert intellectuals, the Chinese government also encouraged discussion on the healthcare reform at the annual “Two Meetings” of the National People’s Congress (NPC), and the Chinese People’s Political Consultative Conference (CPPCC) from 2006 to 2009. At the CPPCC, an advisory body to the government--primarily composed of non-party members--a special committee of professionals representing the health sector conducted discussions, and also held face to face question and answer sessions with the Minister of Health ( 2007). Both members of CPPCC and Representatives from the NPC--China’s legislature--also submitted proposals 24  to the government in regard to healthcare policies (MOH 2007). And, members of both assemblies were interviewed extensively about their positions on the healthcare reform, and the media also invited them to attend public debates on these policies (Sohu 2008b; Sohu 2009). The indicators examined here are consistent with the observable implications for both ‘legitimacy’ and ‘information gathering’.  The annual gatherings of the NPC and CPPCC took place in March of 2006, 2007, prior to the formalization of a plan for healthcare reform by the government. This could possibly imply that feedback from these assemblies was taken seriously by the government. Yet, when the “Two Meetings” were held in 2008 and 2009, the government ministries had already finalized the key components of the reform. Moreover, the “Two Meetings” of 2009, occurred in the first two weeks of March, only three weeks before the public release of the final draft, in April 7, 2009. This could possibly suggest that the “Two Meetings” during these years served primarily as “window dressing” for enhancing legitimacy.  The selection of participants for this participatory forum also point out to both legitimacy and information gathering. The members of the assemblies attending the deliberations on healthcare reform were primarily an elite group of professionals--senior medical doctors and hospital directors, as well as CEOs of pharmaceutical companies. Their participation in the deliberation conveyed to professional elites a sense that they were represented in the process. Yet, because of their practical experience of the medical system, their inclusion also made sense from the point of information gathering. 25   To compensate for the lack of non-elite representation in these deliberations, the official media tried to emphasize and elicit participation of these groups. Even though deliberations on healthcare at the “Two Meetings” consisted of elites, the national TV devoted great attention to the participation of a rural medical doctor and an NPC member, Ma Wenfang, in these discussions (CCTV 2008). Furthermore, in preparation for the “Two Meetings” the website of Xinhua news, the central government’s outlet, invited the public to discuss the issues pertaining to the healthcare reform which concern them the most, and also provide their own advice and recommendations (Xinhua 2007; Xinhua 2008b). In this manner, non-elites gained some representation at the “Two Meetings”. These practices, which seem to have had no substantial impact on policymaking, could suggest that this device was also deployed toward the expansion of deliberation to the general public in order to enhance legitimacy.  Examining the official discourse on the work of NPC and the CPPCC, it is evident that obtaining legitimacy is one of the key goals of deliberation at the “Two Meetings”. The media depicts the “Two Meetings” as forums that enable the discussion on issues that are directly relevant to the people’s livelihood, problems that are of key concern for most of the public (Xinhua 2008b). This discourse on the engagement of the “Two Meetings” in the people’s problems served to entrench an image of a responsive state that is considered about the people’s problem. Similarly, the portrayal of premier Wen Jiabao’s empathy to Ma 26  Wenfang’s description of the poor state of medical services in rural China also assists in crafting this discourse of a benevolent government (CCTV 2008).  In addition, the media coverage of the “Two Meetings” bolstered the notion of open deliberation. The official media report on the discussion at CPPCC between the Minister of Health and members of the assembly emphasized that this deliberation epitomized democracy, and the participants, when interviewed, praised the open discussion and reiterated that idea that they could say whatever they pleased ( 2009). The Minister of Health was also interviewed, and asked to clarify the key points of reform ( 2009).  These rituals of debate and discussion conveyed a semblance of a responsive government that is willing to listen to critique and feedback from society. This notion of government responsiveness was further reinforced by an immense degree of media coverage which emphasized the openness and comprehensiveness of these deliberations.  From the content of the discussion, however, we can ascertain that enhancing legitimacy was not the sole purpose of the government in encouraging deliberation. The proposals and suggestions of the members of the “Two Meetings” discussed in depth key issues, such as the integration of urban and rural medical insurance systems, citizens participation in oversight over pharmaceutical companies, training of medical doctors, the compensation mechanism for medical doctors and other. These comments could ascertain that gathering information is also an important component of this consultation procedure. 27   In addition, at the “Two Meetings”, the Deputy Minister of Health, Huang Jiefu, made contentious remarks. Contrary to the formal position of his ministry, he publicly dismissed the system of shouzhi liang tiaoxian--in which the government covers the expenses of public hospitals, while they remit their revenues back to government--arguing that it would erode the motivation of healthcare providers (China News 2008). He also criticized the consultation with expert intellectuals for the exclusion of the views of the medical personnel from this process. ( 2008). These polemical remarks show that discussions at the “Two Meetings” are not for “window dressing”. They focus on concrete issues of contention.  Judging by the feedback absorbed in the final draft, it is also possible to consider the Two Meetings not only as a forum for enhancing legitimacy, but also for gathering information. According to one account, prior to the opening of the “Two Meetings” in March 2009, recommendations of members of the CPPCC to increase the rate of nurses, and standardize the training of medical doctors were incorporated into the final draft of the healthcare reform (G. Liu 2009). This input may not be directly attributed to the CPPCC, as it was generated before its meeting, yet, it does suggest that the government genuinely considered the views of members of the “Two Meetings”. 3.3 First Online Portal: Indirect Participation of Professionals  Aside from direct interaction between elite professionals and the government, the latter also enabled other professionals to indirectly participate in the policymaking process. In 28  October 2006, the Chinese government opened an internet portal, ”My Advice and Suggestions regarding China’s Healthcare reform”, for public feedback on the healthcare reform. From its opening until July 2007, 5463 responses had been posted.  The opening time of this portal could indicate that information gathering was the primary impetus. In October 2006, when this portal commenced, the Healthcare Reform Coordinating Small Group started its work. Since, at that stage, the Small Group had not yet finalized the key guidelines of the new policy, this participation could have potentially had a significant influence on the policymaking process.  The portal was formally opened to all the people, yet the guidelines for responses could have possibly excluded non-professional audiences. In the statement inviting the public to participate,  respondents were advised to provide suggestions on particular issues such as, health management and delivery, health investment mechanisms, health security systems, supervision of health services (Baidu 2006). This statement most likely targeted people within the medical industry, who possessed experience and practical knowledge of the system.  Looking at the extent of publicity, we see a modest degree of government attempt to promote the online portal. The official state outlets informed the public about it, so that people could attend. Yet, there was no significant attempt to use it for the purpose of public relations. 29    Reading the responses on the portal, one may sense that this was a forum for genuine information gathering, as suggestions were very informative and elaborate. While, at this stage, I am unable to accurately trace what particular feedback from this portal had eventually been absorbed into the policymaking process, it is plausible to assume that it did influence the policymaking process. Issues frequently raised by the respondents--strengthening the infrastructure of grassroots clinics, coordinating between these clinics and public hospitals, and separating pharmaceuticals from hospitals (NDRC 2007)--have all been key issues of attention in drafting the blueprint of reform. More research, nevertheless, still needs to be done in order to ascertain that.  Even though most of the indicators demonstrate that information gathering triggered the opening of the online portal, the official discourse on this portal point out that legitimacy may have been an additional motive. The statement inviting the public to attend the portal conveyed the government’s responsiveness to the people, and its commitment to design a process which guarantees representation. This statement mentioned that: “since this work (of the government) is directly related to the people’s concrete interests, we would extensively listen to insights from all social groups on how to solve the people’s problem of ‘seeing a doctor is difficult, seeing a doctor is expensive’, and seek the suggestions and opinions of the entire society” (Baidu 2006). The notion that the government conducted participation so as to understand and act according to the people’s interests was further reiterated in the official media (Xinhua 2006; Xinhua 2006a). In spite of this discourse on the government’s 30  benevolence, the modest degree of media coverage indicates that legitimacy here took the backseat to information gathering. Since the origins of this participatory forum cannot be traced to fragmentation within the government administration, and the feedback does not necessarily address issue that are of concern to the bureaucratic dispute, the framework of FA here is inconsequential. 3.4 Face to Face Interaction between Non-Elites and the Government  Another participatory forum--which contrary to the “Two Meetings” and the first online consultation--also included broad non-elite representation took place on April 11 and 15 2008, when the State Council invited to its work meeting on the healthcare reform 22 representatives of various social groups. Analyzing the indicators, one can identify legitimacy as the trigger for conducting this forum. The meeting took place in April 2008, when the government ministries were at the late stages of drafting the first blueprint for reform. The selection of participants was designed in a manner that emphasized representation. It included a diverse array of stakeholders. And, while some of participants were elites--expert intellectuals, leaders of the pharmaceutical industry--the majority of the citizens participating represented non-elite groups, an important device for acquiring broad legitimacy. Among the groups attending this consultation were: labor migrants, rural residents enrolled in the rural medical scheme or the rural medical assistance program, officials responsible for the 31  management of rural medicals scheme at the county level, chairmen of trade unions, workers of State Owned Enterprises and foreign enterprises, heads of neighborhood committees, and middle school principals (Xinhua 2008c).  The participation of these non-elite groups was exploited by the government to publicize its responsiveness. In this meeting, premier Wen Jiabao declared that he was now opening the gates of Zhongnanhai--the headquarters of central government--so as to allow the people to air their opinions. At this meeting, the premier said that this was the first time that the government convened such a session. The purpose of the meeting, according to him, was to listen to opinions of healthcare workers, who are at the front line of this healthcare reform, as well as the people at the grassroots level--the target of this reform. The official media amplified this discourse of government’s empathy, stressing that the premier attentively listened to the speakers, asked questions, and also wrote down their suggestions (Xinhua 2008c). This session was widely reported in the media. There is no available public information on the content of feedback generated in the meeting, and there is no indication that it was considered in the policymaking process. If further research ascertains that input from this forum was not absorbed into the final draft of this healthcare reform, then this meeting was clearly intended for enhancing legitimacy. There is no evidence that the opening of this forum had any causal link to FA. 32  3.5 Second Online Portal: Indirect Public Participation  In addition to inviting representatives of the public for a face to face consultation forum, the government also sought to solicit the views of the general public. In October 2008--after the government finalized and unveiled a blueprint for the healthcare reform--a second online portal was opened, and premier Wen Jiabao declared that the public again was invited to submit its views (Xinhua 2008). The process took place from mid October to mid November, 2008. According to government sources more than 35, 000 responses had been received received (China Economics 2008; 2008).  Our indicators, as well as a comparison with the earlier portal of 2006, point out that ‘enhancing legitimacy’ was a central reason for the opening of the internet portal. Yet, they also demonstrate that it was not the exclusive objective of the government. ‘Information gathering was an additional goal.  Examining the timing of the introduction of the portal, we could clearly identify ‘legitimacy’ as a key trigger for initiating participation. While the timing for the first online forum was in October 2006--long before the contours of the policy plan were formulated--the second online portal was opened in October 2008, after the Small Group had already concluded the key principles of healthcare reform, and there was no room for substantial changes.   The selection of participants also indicates that legitimacy was a central prompt for opening this online outlet, yet it does not preclude ‘information gathering’. In the first portal, 33  the official statement invited all groups of society to attend. But, in practice, the statement inviting the people to participate--which urged the public to advise and recommend on specific issues--barred those who lacked professional knowledge from contributing. In the second portal, however, participants were only asked to express their opinions on China’s healthcare reform (NDRC 2008). Media reports indicate that this elicited a more inclusive process. 20% of the respondents, as media reports claim, were rural people, labor migrants and workers--95% of whom earning less than 50,000 Yuan per year. Even though the majority of participants--about 55%--were medical personnel, from reading the responses, it is clear that they were authored not only by senior medical doctors and hospital directors, but also by medical doctors at grassroots rural clinics ( 2008). The composition of participants shows that this participatory forum, compared to the earlier one, was more representative, and potentially helped the government to gain legitimacy. The inclusion of these groups, nonetheless, is not a unique requirement for legitimacy. Information gathering, while mainly relying on feedback from experts and professionals, also, to some extent, entails the solicitation of input from the grassroots level, in order to adjust policies to their needs.  The official discourse on this online consultation portal, however, primarily demonstrates that the search for legitimacy was a major concern. Even if the rate of participation of low income people was exaggerated in official media reports, it furnished the government with a claim for representation of these groups. Official media reports also boasted that many of the respondents praised the current reform, and they cited respondents claiming that the opening 34  of this portal attests to the government’s respect for the people, as well as for its sincerity and resoluteness to tackle the problem of “seeking medical care is difficult and expensive” ( 2008). But, while the official depiction of the participatory forum emphasized the people’s support of the policy and the government’s benevolence, it refrained from discussing the relatively low participation rate--35,000 people out 1.3 billion citizens. The attempt to mask this displeasing facet of public participation is also an indicator for legitimacy. In spite of the low rate of participation, the media devoted a great deal of attention to this portal. This further ascertains that legitimacy underlay the opening of this portal  The online forums also seem to have been utilized not only for enhancing legitimacy. Reading many of the online responses, it appears that rather than raising concrete suggestions on how to solve the problems of China’s medical system, many of the respondents took advantage of this platform to air their grievances regarding China’s healthcare system. Patients criticized high drug prices and hospital pharmacies’ efforts to avoid the selling of cheap medications. Rural residents lamented that the poor state of medical services in rural areas. Pensioners complained about cumbersome procedures for receiving insurance compensation for medical services at their actual places of residence. For medical personnel, this was an opportunity to speak directly to the government about the misconduct of hospital directors without publicly revealing their names, as well as express their dissatisfaction about low wages, stress, overwork, and abuse by patients. (NDRC 2008). Yet, in spite of the 35  frequency of these complaints many of the responses, written by people from the medical industry, did not only include the expression of grievances, but concrete recommendations on how to improve and refine the proposed reform plan. The responses suggest that the search for both legitimacy and information triggered the introduction of this participatory.  The government’s response to the online consultation also validates both theories. The government’s reaction to the people’s complaints epitomized a resort to populism for the purpose of mollifying the public. Following the public lament on the inadequacy of the system and the high prices of medical services, the government decided to hasten its effort to overhaul China’s medical system. While the first draft stipulated that in 2010 the government would engage in the preliminary stage of constructing a basic healthcare system, in the revised version it was changed into a more ambitious plan--from 2009 to 2011, the government would fulfill the five key points of the healthcare reform, including the completion of a construction of a basic medical system. In addition, it was also mentioned that by 2011 the government would seek to provide medical coverage to 90% of the population (Wang 2009c). In the final plan, the government subsidy for purchasing insurance was increased to 120 Yuan per year, and the plan determined a very high sum as the maximum insurance compensation available--6 times the average salary of a locality. The measures to speed up the implementation of the policy do not necessarily contribute to the refinement of the government policies, since acquiring the know-how for an overhaul China’s 36  healthcare is likely to be a protracted process. But, for the short term, these revisions could please the public, and enhance the government’s legitimacy.  However, the government’s response to the feedback from this portal also shows that the framework of ‘information gathering’ is tenable. In the final draft of the healthcare reform, the government, following the public’s suggestions, endorsed several changes that could lead to technical improvements in the policymaking process. For example, after senior citizens retiring in cities where they are not registered as residents complained about the cumbersome procedures for receiving insurance compensation in their new places of residence, the new plan stipulated that simplification of this process for pensioners (Wang Hufeng 2009; 205). Following complaints by medical personnel about overwork and abuse by patients, the new draft announced an increase in the number of nurses per patients, as well as a commitment to improve their working conditions, and protect their legal rights (Wang Hufeng 2009; 220-221). Rather than being influenced by populist tendencies, these changes are of technical nature, and serve to improve the quality of the policy in very specific domains. This establishes that the purpose of initiating this participatory forum, aside from garnering legitimacy, was to gather information. As for FA, there is no evidence that this type of participation was pursued due to conflicts within the bureaucracy. 37  3.6 Mass Media: Amplification of the Online Portal  Concomitantly to the inauguration of the second online portal, the media--following premier Wen Jiabao’s call for the public to openly express their views--also started to actively seek to interview the main stakeholders in the reform--hospital directors, medical doctors, representatives of pharmaceutical companies and patients. The media covered the meetings of the professional associations of these stakeholders and their key suggestions to the government.  As in the case of the second online portal, the timing of participation via mass media could certainly attest to the fact that the government was concerned about legitimacy. This media effort started only after the key principles of this reform had been determined. In addition, the time slated for this participatory forum was also very short, only one month--from mid-October to mid-November. Whereas expert intellectuals debated the healthcare reform for several years, from the outset, this short spell of discussion provided stakeholders with a limited ability to impact policymaking. This could further indicate that this process was about obtaining legitimacy.  The selection of participants for this forum also suggests that the need to enhance legitimacy induced this participatory practice. Looking at the participants, we could see that the media endeavored to solicit the opinions of key stakeholders, such as patients, medical doctors, hospital directors, and representatives of pharmaceutical companies (Finance QQ 2008; JSChina 2008; People’s Health.Net 2008; Sohu 2008; Sohu 2008a; Sohu 2008b; Sohu 38  2008d; Sohu 2008e). This may indicate that the principle of representation, an indicator for legitimacy, underwrote this type of participation via mass media.   The official discourse on this also stressed the responsiveness of the government. In Oct 2008, premier Wen Jiabao announced that the government was seeking for the views of the public on the healthcare reform (Xinhua 2008). In Jan 2009, after participation via mass media had ended, premier Wen Jiabao declared that the plan was viewed favorably by all sections of society, and that the government ministries absorbed many of the suggestions raised in the consultation process ( 2009a).  As in the case of the second online portal, while the premier emphasized broad participation, his statement overlooked the fact that in spite of the media’s attempt at representation, the most visible group in the media were lobbyists for the pharmaceutical industry. The premier’s declaration, which masked the deficit in participation of other stakeholders, suggests that the government utilized participation in order to justify the proposed plan. Aside from the official discourse, the degree of media coverage was high, and that could also indicate that the purpose of this strategy was to publicize the government’s responsiveness.  The examination of the feedback generated through the media uncovers observable implications that are consistent with both legitimacy and information gathering. Some of the media reports consist of cursory interviews with stakeholders which elicited very predictable responses. For example, a patient complaining about the high drug prices, and says that he is looking forward to the introduction of a system of essential medicines. A doctor at a 39  community clinic complained about the low number patients visiting this clinic (Sohu 2008c). Other media reports, nevertheless, exposed the elaborate suggestions submitted to the government by key stakeholders: the pharmaceutical associations proposing to replace the suggested system of the central government selecting the manufacturers with an open and competitive bidding process. They also recommend that the market, rather than the government, would regulate the prices of essential and patented medicines (Pharma 2008). In addition, hospital directors advocated the professionalization of the upper level of hospital managers. They also emphasized the need to train more family doctors (Sohu 2008a). A medical doctor urged the government to raise the prices of patients’ registration fee and operations, so as to decrease the reliance of medical doctors on the sale of pharmaceuticals. For doctors who would still illegally take commissions on pharmaceuticals, she recommended to revoke their licenses (Yin 2008). The feedback from participation via the media included both predictable responses, and technical suggestions for efficiency and improvement.   Given the existing evidence currently available to me on the government’s responses to this participatory forum, it is still difficult to clearly identify the mechanisms at work. The government responded to some of the feedback, yet we do not know whether the responses stemmed from a genuine attempt to gather information, or because of the power of the respondents--representatives of the pharmaceutical industry. 40   In the aftermath of consultation via the media, the government adjusted its policies of procurement of essential medicines. The earlier draft stipulated that the central government would, via bidding, select key manufacturers, or collectively purchase, in a form of direct delivery, essential medicines. While guaranteeing a reasonable profit rate for manufacturers, the central government would set unitary retail prices for essential medicines (Wang Hufeng 2009; 207). Pharmaceutical associations utilized the media in order to launch a public campaign against these centralized procurement system, which, they argued, would limit competition and eliminate many of the pharmaceutical companies (Sohu 2008; Yang 2009; Zhang 2009). Due to their complaints, the government altered the system of procurement of essential medicines. Rather than direct delivery, there would be a unitary delivery system, yet wholesalers would be able to participate. In addition, instead of central government’s control over the process, the unitary system would be managed by provincial governments, which will use a bidding process open to participants from all the country rather than small portion of selected manufacturers. In addition, while the central government would maintain the right to set the guiding retail price for essential medicines, the actual prices would be determined by the provinces according to the bidding conditions (Wang Hufeng 2009; 207)--a measure that would allow for more flexibility in setting prices, and for adjusting it to local market conditions.  These changes do not necessarily validate ‘information gathering’, as it is likely that the government listened to the pharmaceutical associations not because of an endeavor to refine 41  policymaking, but as a response to pressures from a powerful industry. According to a media report, the government actively sought to discuss these policies with representatives of the pharmaceutical industry, and also invited them for direct consultation (Yang 2009). One may wonder whether such efforts to mollify the pharmaceutical industry were also launched with respect to less powerful stakeholders. For example, the government did not strive to find quick responses to hospital directors’ outcry for a new system of government funding for hospitals that would reduce their reliance on the sale of pharmaceuticals. Doctors also complained about low salary and reliance on pharmaceuticals--but, the government has not found swift solutions for this problem. This may suggest that legitimacy was the essence of this participation forum.  It is, nevertheless, possible that that the government endorsed some of the proposals raised by others through the mass media. For example, one of the medical doctors urged the government to increase the prices of registration fees and operations for medical doctors. A complementary government document from November 2009 stipulated an increase in the prices of medical treatment, nursing, operation, and other types of skilled work conducted by medical personnel (NDRC 2009; 3). It is possible that this was done due to feedback from medical doctors, though we have no clear evidence about it, and, thus, it is difficult to ascertain it. But, here too, I have not been able to establish a direct causal link between the hospitals director’s suggestions and the government’s documents. 42   Analyzing the design of this participatory forum, it is evident that this highly publicized procedure was set up in order to enhance the government’s legitimacy, and demonstrate that it seeks the advice of all the relevant stakeholders. Additional research on it, however, may reveal that this procedure, though primarily intended for garnering public support, was also designed in order to gather feedback. FA does not appear to be relevant here.    43  Conclusion Analyzing the instances of participation in the case of the healthcare reform, we can detect a diffuse set of causes that undergirded participation. First, unsettled disputes inside the bureaucracy over parochial interests and protection of one’s turf led the contending parties to open the policymaking process for the participation of expert intellectuals. Even though FA was not the primary cause for the emergence of a lively, high-profile public debate dominated by these intellectuals, the interaction of FA with another cause--an ongoing elite debate over the course of China’s development trajectory--fueled the intensification of this debate. Second, the quest of an authoritarian government to enhance its legitimacy led to the introduction of a myriad of participatory practices which the government belabored to publicize, in order to showcase its responsiveness to society, as well as its commitment to allow for representation of diverse groups. Among the participatory practices initiated in order to enhance legitimacy were the “Two Meetings”, a face to face meeting of representatives of the public with the premier, the second online portal, and participation via mass media. The introduction of these participatory forums, however, not only stemmed from the government’s endeavor to obtain legitimacy, but also from a third cause--the need of an authoritarian regime to gather information from both experts and professionals and the general public. Participatory practices such as the “Two Meetings”, the first online portal and the second online portal were more than a public relations stratagems. Even though in some cases, notably the second online portal, the government embraced a populist response to the 44  public demands, in other cases, the government seriously considered the content of responses, and took measures to implement some of the technical advice received in this process. Similarly, the government’s endorsement of some of the technical advice of expert intellectuals could also indicate that their invitation to solicit blueprints for reform, though primarily motivated by the need to overcome bureaucratic wrangles, was also a genuine attempt to improve policymaking. A fusion of different causes interacted here to generate these elaborate forums of participation.  The drafting of the new healthcare reform evinced a process of extensive participation, where diverse groups were targeted. Participation included not only an elite of expert intellectuals, or professionals working inside the medical industry, but also medical personnel at the grassroots level of the medical system, and low income groups. In addition to including a direct, face to face interaction between participants and leaders of the government, the latter created forums for broad, voluntary participation of the general public through both online portals, and mass media.  These broad and elaborate outlets for participation attest to an emerging form of participatory policymaking process in authoritarian regimes. The insights gained in this study, though still preliminary and in need of further theoretical refinement and empirical details, are relevant to the analysis of other instances of policymaking in China, particularly those that directly affect the lives of the general public. The Hu-Wen era, when the government, under the rubric of ‘harmonious society‘, introduced various welfare policies, and also the 45  upcoming years, when the continuation of economic reforms is expected to require the revision and reformulation of new social policies, may be a fertile ground for applying and polishing the framework of this study. Notable cases may be those of the Labor Contract Law, Education Reform and the New Marriage Law in which the Chinese government also enacted various forums for participation. And, perhaps, a comparison with cases of drafting of social policies, such as the Construction of New Socialist Countryside, where public participation has not been elicited, could also help to strengthen the theoretical foundations of this study.  In addition, this paper may offer a platform for going beyond FA--the dominant paradigm for the study of policymaking in China. It shows that in investigating policymaking, we are required to be to attentive to other types of causes that may prompt participation, such as the quest for legitimacy and the need to gather information.  One of the emerging frameworks that could potentially constitute an alternative or complimentary paradigm to FA is “Authoritarian Deliberation”. This paper concurs with He and Warren’s contention that in China “consultative processes often shade into deliberative processes” (He and Warren 2011; 274). This could certainly be said about the discussions at the “Two Meetings”. Members of these assemblies consulted the government, yet, their discussions and debates exerted a persuasive influence over the government’s decisions. As for the participation of expert intellectuals, we can recognize that they both attended a closed consultation process with the government, and a public debate that turned into deliberation. The debate had its roots in a fierce ideological struggle over the course of China’s 46  development yet, this debate has evolved into an informative process of discussion and deliberation between intellectuals and concerned journalists. It is possible that this debate also had a persuasive influence over both the public and decision makers, at least, in so far as it framed the debate on reform as that of government vs. market. Internet portals and participation of stakeholders via mass media also evinced some forms of deliberation. Diverse voices made public are more than consultation. They create a discursive influence over those who listen to these discourses, including decision makers, even if they do not follow what was suggested. These forms of “authoritarian deliberation”, however, have significant limitations. Since in “an authoritarian regime, elites control the domain and scope of deliberation, and limit citizens’ capacities to put issues into the political agenda” (He and Warren 2010; 274), deliberation among intellectuals and members of the “Two Meetings” often unfolded as a technical discussion. Aside from technical solutions, a key issue for the success of reform, the impact of the current political system on the performance of medical services in China--particularly, the weakness of the legal system and the absence of accountability and proper norms--on the operation of China’s healthcare system was off the limits. Since deliberation was conducted under an authoritarian system, broad participation via internet and mass media was also constrained. Even if these public outlets had the potential to elicit a deliberative interaction among participants, most of the respondents addressed their concerns to the government, since only the government had veto power over 47  the process. Authoritarian deliberation was often delimited to communication between the citizens and the government--not among the citizens.  Beyond adding more empirical knowledge on deliberation in China, this paper could also be relevant to other countries. It would probably be most relevant to regimes that seek to accomplish more than just clinging to authoritarian power. Particularly to autocrats who embrace a developmental agenda, and seek to have their countries integrate into the global economic system--a goal that could be realized only through the collaboration and participation of the public. Even though other developmental authoritarian systems may not introduce deliberation, and may lack some of the notable features of China’s political system, most notably fragmented authoritarianism, they all grapple with a similar dilemma--how to both elicit and contain participation--and often introduce limited participatory practices to overcome this dilemma. Since these regimes are still exploring these practices, and they may be learning for each other, this work could apply to non-Chinese contexts.  A discussion on participatory practices in China entices us to reflect about their potential to generate significant political change--regime change, democratization or a substantial political reform. Judging from the empirical material gathered here, we could say that it is unlikely that these practices would precipitate such outcomes. As we’ve seen in this paper, participatory practices has been designed in order to accomplish functionalist goals in a risk-averse manner. Even if participation is broadened, the government tightly controls the forums, maintains its veto power over policymaking, and, most importantly, it still dictates 48  the discourses that dominate the public sphere, setting taboos for issues that could challenge its authoritarian position. These practices cannot lead to democratization precisely because they are set up to in order to avoid it. 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