# Policy frameworks for promoting public hospital development in major economies: implications for China

## TL;DR

The paper compares public hospital policies in major economies and suggests how China can improve its system by learning from global practices.

## Contribution

The study provides a comparative policy analysis of public hospital development across five major economies and offers tailored recommendations for China.

## Key findings

- Public hospital policies in the U.S., U.K., Germany, Japan, and Singapore differ in financing and governance but aim for efficiency and equity.
- China's public hospital system relies on government leadership and a basic medical insurance system to ensure stability and public welfare.
- The study recommends China adopt international best practices to enhance hospital efficiency and equity.

## Abstract

As the core providers of medical and health services, public hospitals play an irreplaceable role in ensuring basic medical care, safeguarding health equity, and fulfilling social responsibilities. Their operational efficiency and institutional design not only influence the national health status but also relate to the stability and development of the entire healthcare system. Therefore, continuously optimizing support policies and management mechanisms for public hospitals has become a crucial issue for governments worldwide in advancing healthcare system reforms.

This paper systematically reviews the policy trajectories supporting the development of public hospitals in five major global economies, namely the United States, the United Kingdom, Germany, Japan, and Singapore. Primary sources included government legislation and policy documents, official statistical publications issued by health authorities and insurance agencies, and peer-reviewed journal articles indexed in Web of Science, PubMed, and Scopus. The analysis focused on key institutional dimensions, including financing arrangements, governance structures, payment systems, and performance evaluation mechanisms. Through cross-country comparisons and longitudinal historical analysis, it reveals the commonalities and differences among various policy models.

The study finds that in the United States, support policies for public hospitals are primarily market-driven, supplemented by public programs. Public health insurance programs such as Medicare and Medicaid provide funding for public hospitals, and market-oriented management models are relied upon to enhance operational efficiency. The United Kingdom adopts the National Health Service system, which is based on tax financing and constructs a public hospital system that combines government leadership, internal marketization, and performance governance. Germany ensures the financial stability and operational efficiency of public hospitals through a dual governance structure of social health insurance and government capital investment. Under the universal health insurance system in Japan, a refined payment system and a local government responsibility-sharing mechanism drive public hospitals toward efficiency and equity. Singapore centers its approach on government subsidies and the 3M health insurance system, combined with group management of public hospitals, achieving equitable access and efficient operation of healthcare services. In China, the development of public hospitals follows a clear path of government leadership, with the basic medical insurance system serving as a solid guarantee. A diversified compensation mechanism has been established to ensure their stable operation. In terms of management, active efforts are made to advance the reform of separating management from operation while adhering to the core principle of public welfare orientation.

There are differences among countries in the selection of policy tools and practical effects to support the development of public hospitals, but all demonstrate an ongoing balance between ensuring the supply of basic medical services, enhancing the efficiency of the service system, and addressing structural challenges. China should draw on international experience, taking into account its national conditions, to further strengthen the central government's coordinating role, clarify the boundaries of financial investment, optimize health insurance payment and price formation mechanisms, promote the reform of public hospitals toward legal person status and group management, accelerate digital transformation and the implementation of a tiered diagnosis and treatment system, and build an efficient, equitable, and sustainable development model for public hospitals.