Scaling-Up through Piloting:Dual-Track Provider Payment Reforms in China's Health System.

Gaining wide prominence in the global health arena, scaling-up increases the coverage of health innovations emerging from pilots and experimental projects to a larger scale. However, scaling-up in the health sector should not follow a linear "pilot-diffusion" pathway in order to better facilitate local adaptation and policy refinement. This paper puts forth "scaling-up through piloting" as a distinctive pathway for the strategic management of scaling-up in the health sector. It analyzes the recent development of provider payment reforms in China, focusing particularly on the ongoing pilot program, namely diagnosis-related groups (DRGs) and diagnosis-intervention packet (DIP) that are being piloted in a dual-track fashion since 2020. Data were drawn from extensive documentary analysis and 20 in-depth interviews with key stakeholders, including decision-makers and implementers. This paper finds that scaling-up through piloting helps Chinese policymakers minimize the vast uncertainties associated with complex payment reforms and maximize the local adaptability of provider payment innovations. This pathway has forged a phased implementation process, allowing new payment models to be tested, evaluated, compared, and adjusted in a full spectrum of local contexts before national rollout. This phased implementation creates a "slower is faster" effect, helping reduce long-term negative consequences arising from improperly managed scaling-up in a complex system. Error detection and correction, and recalibration of new policy tools can support national level policy refinement in a more robust and dynamic fashion. Several key factors have been identified as crucial for strategic scaling-up: necessary central steering, a pragmatic piloting design, strong technical capacity, and effective policy learning mechanisms.