Background
China has enjoyed rapid economic development since the reform and open policy implementation in 1978. Accordingly, China’s economic reforms have achieved significant success. However, the Chinese healthcare system began to regress in the 1980s, and many problems have been encountered thereafter. For example, from 1978 to 2012, China’s GDP increased at a 17.7 % compounded annual growth rate, whereas its total healthcare expenditure grew at a somewhat lower 15.7 % compounded annual growth rate [
1]. With the economic reform initiated in the early 1980s in China, the healthcare system had to adapt to a new economic approach, namely, shifting from a communal system to market-driven competition.
Unfortunately, this disorientation caused several problems in Chinese society. The SARS outbreak in 2003 shocked the country’s leaders, thereby exposing the inadequacies in the public health protection system and demonstrating government negligence that had left the healthcare system unprepared to deal with its core responsibilities [
2,
3]. Thereafter, the government struggled to maintain a balance between meeting the people’s immediate healthcare needs and developing the healthcare systems with a series of healthcare policies and reforms [
4‐
6]. For example, after three years of planning, China unveiled its ambitious healthcare reform plan in April 2009 by committing an additional CN¥850 billion (approximately US$125 billion) over a three-year period with the provisional goal of affordable and equitable basic healthcare for all by 2020 [
3,
7]. Influenced by health policies and economic investments, healthcare science and services (HSS) research in China began to escalate and develop rapidly.
With the increase in HSS research in China, research collaboration also proliferated in this field. Scientists benefited from intellectual exchanges with foreign colleagues and reduced costs by sharing resources and technologies with other countries [
8]. Apart from improving research capability, international collaboration may enhance productivity and visibility, although visibility improvement varies among countries and fields [
9]. In recent decades, the robust relationship between collaboration and scientific research productivity and academic impact has been studied and documented by Lotka [
10] and others. In general, collaboration exerts positive effects on teams’ outputs and abilities, and cooperative scientific research results have relatively high academic impact, particularly those related to international collaboration. For example, the citations of a paper are partially related to the number of authors, institutions and countries participating in the paper. However, the effects depend on the collaboration type and the partners involved [
11‐
13]. For example, Narin showed that multiple-institution papers are more highly cited than single-institution papers, and papers with a foreign collaborator are more highly cited than domestic papers [
11,
14]. Glänzel demonstrated that the influence of international collaboration on national citation performance also varies considerably between countries. In some cases, no quality advantage exists for one or both partners, such as in certain collaborations among developing or Eastern European countries [
15]. Meanwhile, the collaboration patterns and influences on research productivity or academic impact also vary by discipline [
13,
15]. Therefore, understanding the collaboration characteristics of specific fields could inform the policies on partners’ selection and research performance improvements, and could even contribute to economic development [
16,
17].
This study was built on our previous work which analyzed the global progress and current research trends on health care sciences and services research [
18]. Although the rapid growth and extensive collaboration in HSS research is observed in theory and practice in China, the publication trends, collaboration patterns and their effects on HSS research in this country remain unclear. Limited attention has also been focused on which groups of actors are at the center and at the periphery of the collaboration network. The previous study was a comprehensive scientomentric research from a global perspectives, while this study focuses on China's collaboration relationships in HSS research. Both collaboration relationship and publication patterns were studied on multiple levels and from several perspectives. With the availability of critical data, such as those from the Web of Science (WoS) of Thomson Reuters, scientometricians have attempted to explore the characteristics of international collaboration from various perspectives [
9]. Given the importance of Chinese collaboration in the international context, the current study evaluated the publication trends, collaboration patterns and current research trends of Chinese HSS.
Thus, the objectives of this study are as follows: (1) to study the Chinese HSS publication trends from absolute and relative perspectives, (2) to explore the collaboration patterns and identify the core partners and institutions, and (3) to present the research foci of HSS in China. The results of this study could provide evidence on the current status and recent trends of publication and collaboration in China, as well as indications of this topic’s popularity and citation performance.
Discussion
China has performed well in the HSS field, thereby indicating a continuously rising trend that has increased exponentially in the last 15 years. The growth rate of HSS research in China is significantly faster than that of HSS research in the world and of other fields in China. Recent trends in Chinese HSS research generally suggest a bright future in terms of quantity compared to the HSS research in the world and with other fields in China.
Many factors may have contributed to the rapid growth of international Chinese publications in the HSS fields, such as health policies and reforms, health projects and funds, international collaboration, research evaluation policies or mechanisms, graduate student enrolment expansion and other factors. First, the Chinese healthcare reforms in the HSS field commenced in the 1980s and China has undergone three reform periods [
46]. Meanwhile, numerous milestone events occurred during these periods. In 2006, health officials and decision-makers realized that the previous reforms were unsuccessful; thus, a new round of reforms began [
4,
5]. In April 2009, after three years of planning, China unveiled its ambitious healthcare reform plan by committing to invest an additional CN¥850 billion (approximately US$125 billion) over a three-year period with the provisional goal of providing affordable and equitable basic health care for all by 2020 [
3,
7]. Therefore, these remarkable events have been highly considered by scholars and healthcare institutions, as well as contributed to the growth of Chinese HSS research.
Second, the consistent increase in investments in various healthcare fields enabled China to launch additional health projects and provide funds to support Chinese researchers in conducting high academic impact research. For example, the National Natural Science Fund and the Ministry of Health of China established health management and policy category funds to support HSS research; the financing amount for this program increases annually.
Third, the collaboration between China and other countries or international institutions has become increasingly frequent. The WHO, World Bank (WB) and China Medical Board (CMB) provide training and funds to Chinese researchers. For example, the WB/DFID China Rural Health Project (2008 to 2013) is a typical (and very large) program, which is funded by the Chinese government, a WB loan and a grant from the UK Department of International Development (DFID) [
65]. This project aims to provide experience and a model for promoting rural health reform in areas in China with different development levels. During this process, WB and the UK government supplied financial and technical/academic support for China. CMB also supported Chinese researchers in universities to study health policy and system science-related fields [
66]. These international activities and collaborations may assist Chinese researchers to enhance their research skills and publish additional international papers.
Chinese research evaluation policies also encourage students to publish international papers. This case is evident in the increasing number of universities requiring additional staff members and doctoral and master’s students to publish SCI/SSCI papers as one of their requirements for graduation [
67]. Therefore, the number of international papers increased with the expansion of graduate studies enrolment.
Collaboration between Chinese and foreign researchers is becoming increasingly frequent
The collaboration trends between countries, institutions and authors develop along with the publication growth trends. Moreover, the cooperation of authors is evidently higher than that of institutions and countries. Therefore, Chinese research capacity and international influence in HSS research may continue to strengthen. However, the collaboration of authors is mostly conducted within institutions or countries. The collaboration of China with over two countries in one paper is still infrequent. Given that productivity and are positively related to extent and patterns of collaboration s, Chinese researchers should improve the extent of collaboration with foreign countries and institutions, particularly with developed countries and well-known institutions.
China’s leading partners in HSS research are developed countries, with the quantity of papers resulting from cooperation with the US and the UK leading the way. The academic impact of papers is also generally high for European countries, such as Switzerland, the Netherlands and others. Therefore, international collaboration with these partners could improve the academic impact of Chinese HSS research output. Hence, international collaboration is still necessary for China to enhance its HSS research capacity. Meanwhile, the quantity of papers resulting in cooperation with Asian countries is relatively low, and the academic impact of these papers also needs improvement. The aforementioned situation can also be observed in the analysis of collaboration networks; hence, developed countries have conducted considerable research in this field with China.
This finding is consistent with parallel findings regarding regular scientific research, which is positively correlated with the level of economic development [
68]. As a developing country with a rapidly expanding economy in the last 15 years, China’s strategy to solve its domestic health problems involves utilizing its high output in the health reform domain and cooperating with several developed countries for its health reform needs. Therefore, China could strengthen its collaboration relationship with the aforementioned countries to improve the academic impact of research. In this process, Chinese researchers could also learn advanced methods and valuable experience.
The concentration of HSS research in China is primarily based in universities. Among the top 20 institutions in this field, 17 are universities and the remaining 3 are R&D organizations. A few elite Chinese institutions, including CUHK, University of Hong Kong, Peking University and Fudan University, contributed approximately half of the Chinese studies and have collaborated with many international institutions. Additionally, the collaboration between the institutions of Mainland China and Hong Kong was frequent and close; however, the international collaboration of the former’s institutions was weaker than that of latter’s. Moreover, the papers published by China’s Ministry of Health have a relatively high academic impact because it is a trusted source of information, and most of the ministry’s papers were developed in collaboration with the US and the UK. However, papers from Mainland China are considered low academic impact papers. Mainland China merely has seven institutions, whereas numerous Hong Kong institutions play an important role in Chinese HSS research. Therefore, Mainland China’s institutions should consider strengthening their collaborations with renowned institutions in the HSS field.
Popular research topics are associated with China’s healthcare reforms
The analysis of keywords shows that popular Chinese health reform-centered topics were studied during the last decades. In spite of its extensive range, HSS research in China relatively focuses on healthcare reform, priority diseases (e.g., breast cancer, HIV/AIDS, tuberculosis, schistosomiasis, etc.), health systems performance, QOL and measurement tools, palliative or end-of-life care, old people problems, research methods and other related topics, particularly those associated to China. These topics drew significant attention from researchers and policymakers.
Healthcare system reform in China has been the most important topic during the last 30 years, particularly after the latest reform in 2009. China’s healthcare system reform has achieved major milestones, particularly in health insurance, under the government’s leadership. However, further analysis of the popular topics of the related articles highlighted gaps and challenges that need to be addressed to achieve China’s stated reform goals. First, despite the extensive achievement in the coverage of health insurance in China, particularly the New Cooperative and Medical Scheme (NCMS) and Urban Resident Basic Medical Insurance (URBMI), the effects of health insurance on the reduction of financial risks is still unclear [
69‐
72]. Second, although the objective of the pharmaceutical sector to control drugs is correct, the methods and the effectiveness of such methods are unclear [
73,
74] and relatively little has been published in this area. Third, human resources shortage exists in China; hence, this problem is a major obstacle in strengthening the public health and primary health care of the country [
75]. In addition, retaining qualified health professionals in the rural areas, particularly in the poor and underdeveloped regions, has been difficult because of socioeconomic reasons and the lack of a proper healthcare infrastructure [
3]. Even with the availability of staff members, the lack of incentives (e.g., higher wages, work benefits, paid vacations, etc.) for primary healthcare workers to deliver public health services may be the main hindrance in retaining healthcare human resources in the rural areas. Fourth, reforming public hospitals is one of the key issues in controlling the increase in healthcare expenditures, improvement in the academic impact of care, and reduction of waste and inefficient work performance [
3]. The reform of public hospitals, particularly county and city government hospitals, needs significant attention and considerable effort to improve the academic impact of service delivery. Finally, health services systems (including provision and utilization) in China are disorganized, and the referral systems and the function orientation of different types of hospitals are still unclear. Relatively little has been published on these important topics to date, so these fields may be important frontiers for future Chinese HSS research.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
LY and QY initiated and designed this study. QY participated in the study design, collected the data, conducted the data analysis and wrote the manuscript. KC, QY, JS, ZFH and ZYL contributed to the data analysis and the revision of the manuscript. All authors were involved in data interpretation and have read and given their final approval of this paper.
Kai Chen (KC) M.P.H, Ph.D., is a candidate in School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, and deputy director of Division of Rural Health, Department of Primary Health, National Health and Family Planning Commision of the People’s Republic of China. His academic interests focus on health policy and rural health.
Qiang Yao (QY) B.S, Ph.D., is a lecturer in the School of Political Science and Public Administration of Wuhan University. His academic interests are in health economics, health policy and systems, health services research and scientometrics.
Ju Sun (JS) M.Ec, Ph.D., is an associate professor and deputy director of the Department of Public Administration Management, School of Political Science and Public Administration of Wuhan University. Her academic interests are in health policy, health economics, health security, social welfare and population health.
Zhi-fei He (ZFH) M.Sc, Ph.D., is a candidate in the School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology. Her academic interests are in health policy and rural health.
Lan Yao (LY), M.P.H, Ph.D., is a professor in the School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, and executive director of the Chinese Basic Medical Security Research Center, Huazhong University of Science & Technology. Her academic interests focus on health economics and policy, medical security, community healthcare service, rural healthcare.
Zhi-yong Liu (ZYL), M.S, Ph.D., is an associate professor in the School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology. His academic interests focus on health service research, hospital information management, health statistics.