With the advent of the third healthcare revolution and its gradual inclusion in government agendas, the World Health Report 2013 proposed a key issue of our time, namely, universal health coverage (UHC). The goal of UHC is to provide all people with access to necessary and affordable health services. UHC aims to reduce the inequalities in health coverage within an entire country or area and is a key component in sustainable development and poverty reduction.

As a basic socioeconomic system, a health system is intricately linked with the social, political, and economic development and policies of a specific period in time. It is clear that China is currently in a crucial transitional period of refining a socialist market economy that is operating within the context of rapid industrialization and urbanization. Hence, healthcare reforms in China still face three challenges when resolving the issues of limited access and high costs: First, there is a gap between the high demand for healthcare by the public and the limited capacity of the state. Second, there is a discrepancy between the public’s medical needs and the supply of health services. Third, there is a conflict between the satisfaction of medical staff and the satisfaction of the public. A new solution for effectively resolving these differences is to strengthen governance at the source and enhance system construction. By changing the models of healthcare services and health-seeking behaviors, a health system can place greater emphasis on disease prevention and truly shift from a disease-centered model to a health-centered model. This shift, in turn, will enable the health system to achieve the original goal and ultimate target of providing higher-quality healthcare to the population.

There are inherent logical relationships between the healthcare and social security systems of a country and its political system, economic level, traditional history and culture, and other “native” factors. Nevertheless, the global issues encountered by China in healthcare reforms may have also occurred at some stage in certain developed countries or may currently exist in different forms or to different extents in certain developing countries that are also in transition. For example, these issues may involve the relationship between economic development and investment in healthcare, the balanced distribution of health resources, or the establishment of an orderly hierarchical medical system. Tackling these issues will require us to study and understand the recurring patterns in the development of medical and health services and social security systems from a global perspective. We should also draw extensively from the positive experiences of countries at different levels of development and incorporate these experiences within the real-life conditions of China and Shanghai.

This book starts from a multidisciplinary standpoint and provides a comprehensive explanation of the structures of health systems and the determinants of health. This book also summarizes the basic models and selection of world health systems and systematically compares the characteristics of health system models, development processes, reform measures, and performance evaluations of 12 representative developed countries and 18 representative developing countries. In addition, the book summarizes the common characteristics, experiences, insights, and developmental trends of health system reforms in countries with different levels of development in order to reflect on how these countries have overcome the universal challenges that all countries face. Clearly, this discussion is extremely insightful for our current journey as we explore the improvement of new healthcare reforms in China.

Here, three specific questions at different levels, which readers can discuss and explore, may be raised.

The first question is at the macro level: How can effective institutional arrangements between the government and the market be achieved in the field of healthcare? The world does not currently have an answer to this question. This issue is especially sensitive for China, which is now in a key period of transformation, so the slightest mistake in this regard may affect the progress of socioeconomic transition across the entire country. Among developed countries, the National Health Service in the UK emphasizes planned interventions, whereas the US has implemented a commercial health insurance system that focuses on market regulation. Among the BRICS countries (Brazil, Russia, India, China, and South Africa), the systems in China and Brazil are mainly based on the state’s macroeconomic control, which is subject to moderate market regulation; India and South Africa primarily rely on the spontaneous regulation of the market; and Russia depends on the joint forces of market incentives and state regulation. However, there are substantial differences in the improvement of health performance among the BRICS countries, and these differences are not significantly associated with national income levels. On the surface, no two countries share the same health system. However, further investigation reveals that it is still possible to classify these systems and to identify the patterns resulting from their institutional development. The formation of these systems is generally closely related to two factors. The first is the country’s level of economic development, and the second is the country’s choice of political system. Does the country prioritize market competition to improve the efficiency of healthcare services, or does it prioritize balanced planning to improve the equality of healthcare services? Each country has to choose the emphasis on and extent of these two priorities. If we take the level of economic development as the vertical axis and the degree of marketization and planning in the health system as the horizontal axis, each country will find its own position within this coordinate system. This book aims to classify and explain these patterns by comparing the different health systems of different countries.

Are China’s healthcare reforms currently experiencing over- or undermarketization? I believe that both aspects are present. Overmarketization is manifested in the imperfect compensation mechanisms of public hospitals, operational chaos in drug production, and artificially high drug prices, which have led to issues of fairness. Undermarketization is manifested in the inability to reflect the value of labor and technology, barriers to institutional approval, and staff turnover, which may result in lower service efficiency. With regard to basic medical and health services guaranteed by the new healthcare reforms, government leadership should continue to be strengthened for public and quasi-public goods, with simultaneous efforts to resolve internal market failures and inadequacies. For the development of the health service industry, such as private healthcare institutions and high-end medical services, commercial health insurance, biomedicine, and information technology, China should rely more heavily on interventions by the invisible hand of the market to meet public demand for these diversified health services.

The second question is at the meso level: What direction should be taken in the development of administrative systems for health services and health security? In the early twenty-first century, the social and health insurance systems of Japan, Germany, and other countries combined the functions of healthcare and social security, which facilitated the centralization and coordination of health service provision, health insurance, and supervision by the government. Among developing BRICS countries, India has established an integrated health administrative system based on its national conditions (i.e., the Ministry of Health and Family Welfare), and Brazil has also established an administrative system that brings together healthcare, health insurance, and pharmaceuticals under the Ministry of Health. China’s health management and health security are currently in a fragmented state. For instance, health insurance is scattered among a number of departments, including the National Health and Family Planning Commission, the People’s Insurance Company of China, the Food and Drug Administration, and the Ministry of Civil Affairs, and this fragmentation can easily lead to divided policies and the waste of resources. The relevant departments are more inclined to promote isolated reforms from the perspective of localized interests. Hence, they may fail to integrate effectively into a continuous and coordinated system that is centered on patients’ health, which is not beneficial to the efficiency and quality of the overall health system. If China can take advantage of this tide of comprehensive and deepened reforms, discard the obstacles of entrenched interests, and achieve breakthroughs in the organization of the medical and healthcare management systems, then, within the context of a large-department system, will China be able to reap more benefits in the promotion of synergistic and joint reforms in the fields of healthcare, health insurance, and medicine?

The third question is at the micro level: Can the more mature family physician and hierarchical medical system of developed countries be applied to developing countries, and can it be embedded within China’s system of health and medical services? Although the family physician system originated in Europe, the US, and other developed countries, it is not exclusive to developed countries. For example, in Latin America, the Cuban government began implementing the family physician system in urban and rural areas in 1984 and promoted the system nationwide in the 1990s. In the face of China’s aging population, the continuous increase in health needs, and the rise of medical costs, it is necessary to strategically shift forward the allocation of health resources, encourage high-quality medical resources to trickle down, strengthen the construction of the primary health care system, and enhance the public’s health awareness and competency.

These measures will gradually realize the transformation from disease insurance to health insurance discussed in this book, which will ensure that health services will be more efficient, thereby reducing the economic burden of healthcare on China’s residents. China’s policy actions in the new healthcare reforms are to “safeguard basic health needs,

Another issue is ensuring that the health insurance payment mechanism for GP services can be transformed from a fee-for-service system to the more advanced capitation system in order to implement a healthcare system that involves designated healthcare institutions, community first-contact care, and hierarchical referral systems. Finally, there is the issue of constructing the internal interest-oriented mechanisms of regional medical consortiums.

Can strong evidence or reasonable solutions to address these questions be found in this book? Should China rely on the experiences and initiatives of developed countries, or are the practices and patterns of developing countries more applicable? Where can we find more scientific and more rigorous evidence to support the government’s determination to promote the reform ideas mentioned above? Readers who are interested in these questions can refer to the 2005 first edition and 2012 second edition of Medical Service and Insurance System in Developed Countries and Areas, which can be read in conjunction with this book. Different readers may have different reactions. This book is based on the admirable international vision upheld by Dr. XIAOMING SUN, his keen long-term observations on the reforms and developmental trends in international health systems, and his reflections on these observations, with a special emphasis on his focused research on developing countries in recent years. It systematically introduces much of the latest objective data, reform content, and empirical analysis, which further enables the book to be more comprehensive, rich, and detailed. Regardless of whether the readers are policymakers, scholars, or even members of the public, this book may provide each and every one of its readers with a valuable basis for the implementation of new healthcare reforms. Therefore, I am very glad to have been given the opportunity to write this Foreword. I also urge all readers to share with the author any ideas or opinions you may have after reading this book, which will allow us to contemplate and design more rational and scientific models together. Doing so will help us to promote new healthcare reforms in Shanghai, or even in China, and will encourage the active offering of advice and suggestions to the relevant decision-making departments of the government, thus enabling us to contribute to China’s early establishment of a complete, scientific, and rational health system.