This chapter shows how the paternalist policy style impacts social policy implementation at the provincial level and below. The top-down approach in paternalist provinces produces relatively standardized social policy but reduces opportunities for officials to innovate and tailor policies to local conditions. Fiscal transfers from the center often foster corruption and dependency in these provinces. Thus, many paternalist provinces have experienced rising inequality despite targeted policies and transfers. While focusing on health policy in paternalist provinces, this chapter also discusses the impact of paternalism on education, poverty alleviation, and housing.

Mixed provinces exhibit elements of pragmatism in addition to elements of paternalism. They tend to be more politically open than paternalist provinces but more restrictive than their pragmatist counterparts. This combination produces a policy style in which provincial leaders take a top-down approach to policymaking and standardize new policies across the province yet tend to be relatively frugal in their social policy allocations both in relative and per capita spending. In some cases, mixed provinces are caught in the middle: they do not generate as much revenue as coastal provinces, but they are not poor enough to be eligible for certain fiscal transfers from the central government. As a result, the budget for social policy in these provinces is often among the smallest in the country. This chapter focuses on health policy in mixed provinces, while also discussing the impact of a mixed policy style on education, poverty alleviation, and housing.

Due to uneven economic reforms, Chinese provinces developed distinct approaches to governing that shaped social policy priorities and policy implementation in the 2000s. This chapter presents the book’s argument in the context of research on social policy and Chinese politics. The chapter synthesizes previous research on the welfare state in developing countries, social policy in China, and decentralization in Chinese politics. The chapter also explains the book’s theoretical framework of policy styles. The chapter concludes by discussing research methods and the structure of the book.

The conclusion recapitulates the book’s argument that Chinese provinces take different approaches to governing, which have impacted social policy implementation. This chapter discusses how recentralization under Xi Jinping may interact with local approaches to governing. The chapter also examines how policy style may have exacerbated local actors’ initial response to the novel coronavirus in 2019. The chapter concludes by discussing how the policy-style framework could be applied to subnational analysis beyond China and the broader implications of the argument.

Since 1949, the Chinese party-state’s approach to health policy has fluctuated with the vicissitudes of politics, oscillating between neglect and an instrumental use of healthcare to promote state legitimacy. This chapter examines health policy in China from 1949 until the 2000s, with a focus on rural areas. During the Maoist period, two factors hindered the erstwhile Ministry of Health in improving health services: budget constraints and political oscillations that prioritized ideology over expertise. In 1978, Deng Xiaoping initiated market reforms and subordinated healthcare and social policy to economic growth. In the early 2000s, due to pressure from society, shifts in governance style, and encouragement from at home and abroad, the Chinese government initiated a dialogue on healthcare reform that culminated in the 2009 plan to overhaul the health system. But because local government was still primarily responsible for funding health policy and faced budget constraints, legacies of health policy in the second half of the twentieth century continued to impact healthcare in the 2000s.

Local government in China is largely responsible for funding social policy and has significant control over the specifics of program design and implementation. Therefore, the same policy can look quite different across provinces and even across counties within the same province. What accounts for local variation in social policy provision? This chapter provides a framework of provincial policy styles and demonstrates how these distinct ways of governing help explain variation in social policy implementation. First, the chapter presents an index of policy styles to classify Chinese provinces based on their dominant policy style: pragmatist, paternalist, or mixed. Then, the chapter examines how provinces diverge in their social policy priorities using provincial social policy spending to measure social policy priorities. The analysis finds that pragmatist provinces are more likely to prioritize education and healthcare, while paternalist provinces are more likely to prioritize poverty alleviation and housing.

This chapter shows how pragmatist provinces shape social policy provision through the devolution of responsibility to local government. Pragmatist provinces have followed Deng Xiaoping’s “do what works” approach to the policy process. Despite the risks within an authoritarian system, officials in pragmatist provinces are more likely to experiment and innovate. These provinces devolve more responsibility to their localities, which offers opportunities for local officials to learn new skills and develop capacity in new areas. However, as they are generally wealthier, pragmatist provinces receive fewer fiscal transfers from the center for social policy. Therefore, they sometimes drag their feet in implementing unfunded mandates that do not coincide with their provincial priorities. While focusing on health policy in pragmatist provinces, this chapter also discusses the impact of pragmatism on education, poverty alleviation, and housing.