## **Chart 1 Accountability relationships for healthcare in cities**

<!-- Start of picture text --> Central Government Weak and weakly enforced regulation<br>Nearly 20 ministries and agencies involved in health policy, Weak monitoring and evaluation<br>including MOF, NDRC, MOH, MOLSS, MOCA Limited funding<br>Difficulties in policy coordination<br>Difficulties in ensuring policy implementation<br>Health insurance schemes<br>National priorities, policies, targets and standards<br>Basic Medical Insurance, social insurance for<br>Administrative controls, including price controls and<br>the unemployed, government insurance, and<br>input controls (personnel, wages) commercial insurance<br>Limited enforcement, monitoring and funding<br>Processing of reimbursement claims<br>Little “active purchasing”<br>Different levels of sub-national government<br>Weak capacity to monitor providers<br>Provincial, municipal and district/county governments<br>The division of responsibilities is unclear<br>Difficult to coordinate policy implementation Weak purchasing role<br>Capacity at the district/county level uneven Weak monitoring<br>Weak financial relationship<br>Weak mechanisms Weak and weakly enforced regulation<br>for citizens’ Weak monitoring and evaluation Pharmaceutical<br>feedback Limited funding producers and<br>Providers<br>distributors<br>Maximize revenues<br>Compete in selling<br>Provision of care (regardless of their level<br>profitable<br>Distorted incentives and ownership)<br>medicines through<br>Citizens Pay linked to revenues providers and<br>Lack information Under-provide basic care directly to citizens<br>Pay most medical bills Not able to act as active and cheap “essential” Under-supply<br>upfront purchasers and monitor medicines cheap “essential”<br>Those insured can performance Over-provide profitable care medicines<br>obtain partial Weak feedback mechanism and profitable medicines<br>reimbursement Payment of fees for care Commissions<br>paid<br>Claims for reimbursement<br>Weak citizens’ feedback mechanism<br><!-- End of picture text -->

# **The role of citizens**

**_As the survey also illustrated, citizens have had limited information and few options to hold service providers or local government officials directly accountable._** The institutional mechanisms to safeguard the citizens’ interests in utilizing public services are yet to fully emerge.  Similarly, mechanisms to support citizens’ empowerment and voice are yet to be fully established.  The citizen scorecard survey illustrates that while many citizens share their discontent informally, very few feel empowered to complain formally and seek any redress. In recent years, there have been signals of gradual improvement, including several court cases satisfactorily resolving citizens’ complaints with respect to public services.<sup>23</sup> The

> 23  Notably, in big cities such as Beijing, Shanghai and Guangzhou, courts have been reported as occasionally addressing citizens’ complaints on health care quality, schooling fees, teacher behavior, and similar.  In provinces and at the subprovincial level, while courts deal with severe complaints, complaint hotlines and other local mechanisms commonly accept citizens’ complaints.

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