Work

From expansion to intelligent governance: structural transformation and regulatory paradigm reconstruction in China’s health insurance reform: a systematic literature review on the evolution and future trajectories of health insurance fund supervision

Year: 2026

Type: review

Abstract: Background Over the past quarter century, China has undergone three transformations in healthcare financing: from employer-sponsored coverage to universal enrollment, then toward quality- and intelligence-oriented governance. This review examines the evolution and future of medical insurance fund supervision in China. Methods Five databases were searched on June 15, 2025. Included publications addressed fund supervision, payment reform, intelligent technology, sustainability, equity, or anti-corruption in China. MMAT and AMSTAR-2 criteria were used for quality appraisal. Each publication was independently assessed by two reviewers using the MMAT screening questions and domain ratings; disagreements were resolved through consensus discussion, with an independent third assessor arbitrating unresolved cases. Inter-rater reliability on a 20% random subset yielded substantial agreement (Cohen’s κ = 0.82). PRISMA 2020 guidelines were followed; no PROSPERO registration was made. Results Three core findings emerged via the Intelligent Supervision Integration (ISI) framework (data, algorithm, institution layers). First, fund supervision evolved through three phases, with the 2018 NHSA establishment as pivotal. Second, DRG/DIP reforms contained costs but generated upcoding and cost-shifting. Third, ML-based and blockchain-based fraud detection have transitioned to operational deployment. Conclusion The ISI framework explains China’s transition to intelligent governance. Six prospective trends are identified: (1) data-driven supervision, (2) federated learning for privacy-preserving analytics, (3) blockchain-based full-chain supervision, (4) intelligent actuarial early warning systems, (5) institutionalized integrity governance, and (6) localization-optimized payment reform.

Source: Frontiers in Public Health

DOI: 10.3389/fpubh.2026.1904242

Author: Zeyu Zhu

Institution: Guangdong Medical College

Language: English

Topic: Healthcare Systems and Reforms

Subfield: Finance

Field: Economics, Econometrics and Finance

Domain: Social Sciences

SDGs: Peace, justice, and strong institutions, Good health and well-being

Open Access status: gold

Estimated APC paid: $3,801