Historical roots of hospital-centred operational governance in China: a path dependence analysis and its implications for global health system reform
Jackie Zhanbiao Li, Duo Wang, Xin Li, Menglan Zhu, Yingying Tiong, Yingqian LaoBackground
Hospital-centred operational governance has been a persistent feature of China’s health system. While this model has supported administrative control, rapid service expansion and organisational standardisation, it has also contributed to the continued concentration of resources in hospitals, constrained local flexibility and the relative marginalisation of primary healthcare. This study examines, from the perspective of path dependence, how this governance model gradually emerged and persisted from 1835 to the present.
Methods
Drawing on historical studies, policy documents, institutional historical data, official materials and comparative global health literature, the study identifies seven phases in the historical evolution of hospital-centred operational governance in China: missionary introduction and early administrative formation; early institutional formation; nationalist integration and public function expansion; wartime adaptation and emergency coordination; socialist consolidation and planned administration; market transition and managerial modernisation and optimisation, digitalisation and performance governance.
Results
Across these stages, four self-reinforcing mechanisms collectively stabilised this pattern: institutional steering, functional expansion, managerial standardisation and market-oriented transformation. The evidence indicates that hospitals became dominant not simply because they appeared earlier but because they repeatedly accumulated administrative visibility, professional authority, technical capacity, fiscal channels and reform implementation functions.
Conclusions
For health system reform, the findings suggest that strengthening primary healthcare and improving equity require technical management reforms to proceed in parallel with changes in governance power, financing incentives, resource allocation, workforce status and data infrastructure. The global health implication is that countries pursuing universal health coverage should avoid allowing hospitals to become the default centre of finance, information, professional prestige and policy implementation.